Welcome to the Homeless Leadership Coalition, where we are working together to prevent and end homelessness in Central Oregon. 

To help us better connect with partners in this effort, we would like to have you - as an individual or as an organization - complete this brief membership form. There are no requirements for being a member, but it helps us as a coalition know who is participating and working in partnership. 

Only one form is needed per agency, group, or specific department of a larger organization. You can fill in additional people who would like to be contacts/representatives or on our mailing list. Please note: all agencies, groups, or individual members will be listed on the HLC website unless you request not to be in the comments box at the end of this survey. 

Thank you and we look forward to continuing the work together!

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* 1. Contact Information

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* 2. I am registering as an...

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* 3. On question 2, I selected registering as an Agency/Group Representative. The name of the Agency/Group I am representing is:

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* 4. The Agency/Group I am representing is:

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* 5. Additional Contact Information:
Please list all names and emails of those from your agency/group who wish to participate in the HLC. Indicate if anyone does NOT want to be added to the HLC email list.

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* 6. I/We work on Homeless/Housing Issues in this Community (check all that apply):

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* 7. I am (please check one of the following):

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* 8. I/We represent or work in these particular areas:
(If more than 1, please choose top 2 that you focus on):

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* 9. I am interested in partnering with the HLC on:

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* 10. Please share any other information you would like us to know about you or your interest and participation in the HLC:

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