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* 1. Name

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* 2. What county do you represent?

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* 3. There are 5 health and well-being priority areas identified, please rank them in order of importance (1 being highest, 5 being least), based upon community need.

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* 4. There are 5 health and well-being priority areas identified, please rank them in order of importance (1 being highest, 5 being least), based upon what you perceive is most important.

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* 5. Are you interested in being a co-facilitator for one of the priority areas listed below:

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* 6. Are you interested in serving on a sub-committee for one of the priority areas listed below:

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* 7. Is there another group/coalition/board in the community coordinating this, or similar, work in the community?

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* 8. If you answered yes to number 7, that there is another group coordinating this work, please list the priority area(s) they address, the group's name, a primary contact, the community they serve, and a brief description of what they do:

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* 9. To be efficient and effective with everyone's time, and to address community concerns regarding health and well-being, what are your expectations of the Healthy Communities Coalition?

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* 10. We are establishing a leadership team for the coalition, two representatives from each county will be identified. Are you interested in being on the leadership team?

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