Community Participation Form

Thank you for your interest in having Marshfield Clinic Health System as a partner. This form is intended to help MCHS better determine participation needs and the local MCHS representative best qualified to join. Once completed, the form will be reviewed by the Community Involvement and Social Accountability (CISA) team and MCHS leaders for final determination. This process may take several months so please be patient with us. Thank you!

Question Title

* 1. Please provide your name and title

Question Title

* 2. Please provide your email and phone number

Question Title

* 3. What is the name of the community partnership, group, or coalition?

Question Title

* 4. Location of the organization (city/county)

Question Title

* 5. Describe the purpose of this community group, partnership or coalition and the population?

Question Title

* 6. Does this position require any certain qualifications? (for example R.N.)

Yes