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Community Healthcare Coalition Greater Prince William Membership Interest Form
Would you like to receive Coalition updates, join in meetings or participate in Work Groups?
Please fill out this form to let us know how you would like to be involved.
OK
1.
First Name:
2.
Last Name:
3.
Organization (if applicable):
4.
Job Title (if applicable):
5.
Email:
6.
Physical Office Location (if applicable):
7.
State:
8.
How did you hear about the Coalition?
Friend
Colleague
Manager
Neighbor
Email/Newsletter
Website
Other (please specify)
9.
Strengths/Skill sets (Optional)
Admin (ex. Notetaking)
Technical Writing
Research Tasks
Graphic design
Data Analysis (qualitative or quantitative)
Evaluation
Grant writing
Communications Writing
Fundraising
Connections to Policy Makers or Regulatory Agencies
Public speaking
Subject Expertise in ____________
Microsoft office (which programs):
Access to in-person meeting space
Other:
Other (please specify)
10.
Please indicate your level of interest of participating in Coalition activities (you can choose any or all the options below):
I would like to receive Coalition updates via email
I would like to join the Neighborhood and Built Environment work group’s monthly meeting on Zoom.
I would like to join the quarterly Coalition meetings on Zoom.
Other (please specify)
11.
Select which option best describes you
I live in Prince William County
I live in the City of Manassas
I live in the City of Manassas Park
I live outside of the Greater Prince William area
Other (please specify)
You're All Set! Thank you for completing this form. If you have any questions, please email pwhd@vdh.virginia.gov.
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