CORE Membership Form

Our Mission: We are a non-profit coalition bringing racial equity to mental health supports for people of color through innovative community collaborations.  Our vision is:  Healthy Lives, Whole Communities. Our principles are:   inclusive, transparent, responsive and nimble, mindful, equity operationalized, giving voice.  
Our priorities are mental health and racial equity.

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* 1. Individual's Name

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* 2. Organization or Coalition Name

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* 3. Address

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* 4. Telephone

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* 5. Website

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* 6. Primary e-mail contact

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* 7. Organizational Mission

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* 8. If this is an organization/ coalition membership, list leadership/management point person (name/title)

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* 9. What type of organization or role you represent in the community?

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* 10. Title

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* 11. Email

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* 12. Telephone

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* 13. Race/Ethnicity

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* 14. Preferred Gender Pronouns

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* 15. Please include any comments here.

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