COALITION MEMBERSHIP FORM

connecticut

health improvement coalition

Partners Integrating Efforts and Improving Population Health

COALITION MEMBERSHIP FORM

Purpose: By completing and returning this form, you indicate an interest in becoming or staying involved in the Connecticut Health Improvement Coalition. As a Coalition member, you become part of a system of partners working together to achieve the vision and goals of Healthy Connecticut 2020 and improve the health of Connecticut residents. You and/or your organization may be identified on the website as a member of the Connecticut Health Improvement Coalition, receive information and updates, and have opportunities to participate in Action Teams or other implementation activities of the State Health Improvement Plan.

Instructions: Please complete this form and click on the “submit form” button in the upper right corner and follow the prompts to send via your email provider. Another option would be to save a copy of the completed form as a PDF document and send it as an attachment to HCT2020@ct.gov .

Contact Information:

Contact Name: Credentials (optional):

Position Title:

Name of Agency: Name of Program:

or /Organization or /Service

Street Address:

City/Town: State: Zip:

Telephone No. Extension: Fax No.

I will participating as:

The designated representative for my agency An individual

My agency/organization will provide a link on our web page to the Connecticut Health Improvement Coalition web page(www.ct.gov/dph/SHIPCoalition):

Yes No

The scope of my agency's/organization's work is (check one):

Please indicate which sector best describes your agency/organization (select one)

(If other please specify)

SHIP Story

Connecticut State Department of Public Health