Community Healthcare Coalition Greater Prince William Membership Interest Form

Would you like to receive Coalition updates, join in meetings or participate in Work Groups?

Please fill out this form to let us know how you would like to be involved.

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* 1. First Name:

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* 2. Last Name:

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* 3. Organization (if applicable):

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* 4. Job Title (if applicable):

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* 5. Email:

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* 6. Physical Office Location (if applicable):

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* 7. State:

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* 8. How did you hear about the Coalition?

Friend

Colleague

Manager

Neighbor

Email/Newsletter

Website

Other (please specify)

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* 9. Strengths/Skill sets (Optional)

Admin (ex. Notetaking)

Technical Writing

Research Tasks

Graphic design

Data Analysis (qualitative or quantitative)

Evaluation

Grant writing

Communications Writing

Fundraising

Connections to Policy Makers or Regulatory Agencies

Public speaking

Subject Expertise in ____________

Microsoft office (which programs):

Access to in-person meeting space

Other:

Other (please specify)

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* 10. Please indicate your level of interest of participating in Coalition activities (you can choose any or all the options below):

I would like to receive Coalition updates via email

I would like to join the Neighborhood and Built Environment work group’s monthly meeting on Zoom.

I would like to join the quarterly Coalition meetings on Zoom.

Other (please specify)

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* 11. Select which option best describes you

I live in Prince William County

I live in the City of Manassas

I live in the City of Manassas Park

I live outside of the Greater Prince William area

Other (please specify)

You're All Set! Thank you for completing this form. If you have any questions, please email pwhd@vdh.virginia.gov.