AVPH Membership Application

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If you are interested in becoming a member of AVPH, please complete the following application and submit online.
Name
Title
Address
Address (Continued)
City
State
Zip Code
Work Phone
FAX
E-mail
I am interested in the following membership type.


Area of interest : Select any of the following options that apply.
Asthma Coalition

Resource Directory

Mental Health

Healthy Families Enrollment

Policy Advocacy

Older Adult / Disabled

Transportation

Grant Writing

Dental Coalition

Environmental Health

HIV / AIDS

Wellness

Emergency Access

Mental Health in Schools

Neighborhood Leadership Training

Transitional Youth
Primary Representation : Are you representing...




If you are representing yourself, check all that apply:

Parent

Youth

Senior

Service Recipient

Other

If you represent a Service Provider please select from the drop-down menu below:
If you represent a Community Group please check which apply:
Business Organization

Cultural / Arts

Grassroots / Community Organization

Inter-Faith Council

Local School District

PTA

Youth Organization
What skills / experience do you bring to the collaborative (such as grant writing,
policy advocacy, neighborhood leadership or marketing)?
Name of agency, organization (if applicable) :

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