Signup as a Members - to the Greater Southern Brooklyn Health Coaltion

Application Form to Join GBHC as a Member Organization

First Name

Last Name

Company or Organization

Address

City

State

Postal Zip Code

Phone

E-Mail

Website

Name of Executive Director

Name of President/Chairman

Names of Additional Staff to include in the GBHC database
(Include as many as you see fit.)

Type of Organization: (Check all that apply.)

Community-Based

Faith-Based

Borough-Wide

Hospital/Health Center

Social Services Agency

Other (explain)

Other

Communities Being Served: (Check all that apply.)

Children

Youth

Adults

Women

Men

Aging

Other (explain)

Other

Disease Specific

Ethnic Specific

Faith Specific

Location Specific

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

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

English

What assistance/training/workshops would most interest you?

Financial Management

Grants Management

Proposal Writing

Cultural Competency

Negotiation & Mediation

Effective Outreach Strategies

Health Topics

Other

Comments you would like to share:

Comments

Please mail or bring to the Office:

Organization's Mission Statement (Official Description & Purpose - 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: $1,000
For Budgets Greater Than $5 Million: $500
For Budgets Between $1 Million and $5 Million: $250
For Budgets Less Than $1 Million: $100

Person Completing Application:

Name of Person Entering Application

Enter Today's Date

CHECK YOUR FORM CAREFULLY BEFORE YOU SUBMIT IT.

Member Info: