GBHC: Greater Brooklyn Health Coalition
     Working to make Brooklyn a Healthier Place

Application to Join GBHC as a Member Organization

First Name

 

Please mail or bring to the Office:

  • Organization's Mission Statement
    Official Description - include brochure if available)
  • List of Officers
  • If an umbrella organization, please list all constituent organizations
  • Membership Dues Payment.

 

Membership Dues for the current year:

  • Hospitals, private practices, and for-profits: $1,000
  • Non-Profit Budgets Greater Than $5 Million: $500
  • Non-Profit Budgets Between $1 Million and $5 Million: $250
  • Non-profit Budgets Less Than $1 Million: $100
  • Individuals: $100
Last Name
Organization
Address
City
State
Postal Zip Code
Phone
E-Mail
Website
Name of Executive Director
Name of President/Chair
 Names of Additional
  Staff to include.

Type of Organization: (Check all that apply.)





(explain)

 

 

Communities Being Served: (Check all that apply.)







 

(explain)


 

 
Next: Page 2
Please indicate the areas and neighborhoods of Brooklyn where your organization provides services. Please include Sections and Community Boards.

 
  		 

Please indicate the Language Capacity/Focus of your Organization. (English is the default.)


 

  
What assistance/training/workshops would most interest you?





 
 

Comments you would like to share:

 

Person Completing Application:


DON'T FORGET:

Please include your check
with your application form.