Membership Form

Please submit by February 5, 2018 in order to be eligible to vote in the 2018 Steering Committee election to be held in spring of 2018.

CHNA 17’s mission is to promote healthier people and communities by fostering community engagement, elevating innovative and best practices, advancing racial equity, and supporting reciprocal learning opportunities to address the needs of the most marginalized members of our communities.  Our vision is:  Healthy Lives, Whole Communities. Our principles are:   inclusive, transparent, responsive and nimble, mindful, equity operationalized, giving voice.  
Our priorities are mental health and racial equity.

Region:  Arlington, Belmont, Cambridge, Somerville, Waltham and Watertown.

Members

Eligibility:  Membership is open to any non-profit organization, coalition, hospital, community health center, individual and municipal government, or for-profit businesses that serves the residents of any of our 6 communities and whose work aligns with the mission of CHNA 17.  Active members are individuals who complete a membership form, attend at least one event per calendar year in addition to the annual meeting, and are on the mailing list. Active members may participate in voting on accepting new steering committee members in the elections held at CHNA 17’s Annual Meeting each year, and the CHNA 17 annual budget.

Benefits and Responsibilities:  Members have access to all CHNA 17 data and educational, and informational materials.  Members are expected to support and promote the mission of CHNA 17 through their work and through providing input on CHNA 17’s work and when possible, provide active participation in ad hoc committees.

Please note, we have individual and organizational memberships.  For an organizational membership, leadership of the organization needs to sign off on this, and a point person from the leadership needs to be listed below.  This is not necessary for an individual membership.

Individual's Name

Question Title

* 1. Individual's Name

Organization or Coalition Name

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* 2. Organization or Coalition Name

Address

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* 3. Address

Telephone

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* 4. Telephone

Website

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* 5. Website

Primary e-mail contact

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* 6. Primary e-mail contact

Organizational Mission

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* 7. Organizational Mission

If this is an organization/ coalition membership, list leadership/management point person (name/title)

Question Title

* 8. If this is an organization/ coalition membership, list leadership/management point person (name/title)

Designated individual representing this organization or coalition at CHNA 17 Steering Committee elections
Name

Question Title

* 10. Name

Title

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* 11. Title

Email

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* 12. Email

Telephone

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* 13. Telephone

Race/Ethnicity

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* 14. Race/Ethnicity

Preferred Gender Pronouns

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* 15. Preferred Gender Pronouns

Please include any comments here.

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* 16. Please include any comments here.

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