Capital Area Public Health Advisory Council (PHAC) - Membership Application

Thank you for your interest in becoming a member of the Capital Area Public Health Advisory Council (PHAC). To confirm your membership, please provide your contact information and complete the following brief survey.

Question Title

* 1. If you represent a municipality, county, or SAU, please select your organization from the drop-down box. Otherwise, please specify the name of your organization in the text box below.

Other (please specify)

Question Title

* 2. Please identify the name and contact information for the individual who will represent your organization as a member of the Capital Area Public Health Advisory Council (PHAC).

Name: *

Title: *

Address: *

Address 2:

City/Town: *

ZIP: *

Email Address: *

Phone Number:

Question Title

* 3. In addition to email communications regarding the PHAC, please let us know if you would like to receive email correspondence regarding any of the following subcomittees/workgroups of the Capital Area Public Health Network. Please check all that apply.

Substance Misuse Prevention

Youth Leadership Councils

Emergency Preparedness

Medical Reserve Corps

Regional Sheltering

Suicide Prevention

Heroin Concerns

Please add additional email addresses to receive correspondence and for which subcommittee/workgroup.

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* 4. Please rank the following 10 public health concerns in order of importance to your municipality, SAU, business, or organization, with 1 being the highest priority/concern and 10 being the lowest priority/concern.

Asthma

Cancer Prevention

Emergency Preparedness

Healthy Mothers and Babies

Heart Disease and Stroke

Infectious Disease

Injury Prevention

Misuse of Alcohol and Drugs

Obesity/Diabetes

Tobacco

Question Title

* 1. If you represent a municipality, county, or SAU, please select your organization from the drop-down box. Otherwise, please specify the name of your organization in the text box below.

Question Title

* 2. Please identify the name and contact information for the individual who will represent your organization as a member of the Capital Area Public Health Advisory Council (PHAC).

Question Title

* 3. In addition to email communications regarding the PHAC, please let us know if you would like to receive email correspondence regarding any of the following subcomittees/workgroups of the Capital Area Public Health Network. Please check all that apply.

Question Title

* 4. Please rank the following 10 public health concerns in order of importance to your municipality, SAU, business, or organization, with 1 being the highest priority/concern and 10 being the lowest priority/concern.

Question Title

* 5. Do you have any other comments, questions, or concerns?