Organization memberships make the organization, network, program, etc. the primary member with an identified key contact. If additional individuals of the "organization" want to be members, they should sign up as Individuals. Email us if you want to know if your organization is already registered ca4health@phi.org . Only sign up the organization if you have (been given) sufficient authority to do so.
Membership Type (PLEASE SELECT ORGANIZATION):
Organization name:
Type of organization
Nonprofit
Philanthropic
Private
Government
Other
Type of Organization. If other, describe:
Organization Size (# of Staff)
Contact First Name:
Contact Last Name:
Email:
Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
U.S. Minor Outlying Islands
Virgin Islands
Armed Forces Americas
Armed Forces Europe, the Middle East, an
Armed Forces Pacific
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut Territory
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Zip:
-
Zip Suffix
County:
Organization / personal website:
Social Media Presence (provide links / handles)
Primary population focus (choose up to 3)
Primary population focus. If Other, describe
Geographic reach of your work / interest
City
County
Regional
Statewide
Classification of primary geographic areas of focus/interest (choose up to 2)
Classification of primary geographic areas of focus/interest. If other, describe:
Primary settings of work / interest (choose up to 3)
Primary settings of work / interest. If other, describe:
Primary topical focus areas of work / interest (choose up to 3)
Primary topical focus areas of work / interest. If other, describe:
Primary competency areas (choose up to 3)
Primary competency areas. If Other, describe:
Are you / your organization interested in engaging with CA4Health on advocacy efforts?
Yes
No
Are you / your organization open to being contacted for speaking engagements by other CA4Health members?
Yes
No
Any additional information you would like to share:
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