On-line Form Please submit after completing.

Membership Form * indicates required fields    *Name/Title:   *Date:   Agency/Organization:   *Address:   *Home Phone:   *Work Phone:   *Email address:   I am willing to come to meetings.:  Yes  No   I am willing to participate with Action Teams.:  Yes  No   I am willing to share CHL information.:  Yes  No   I am willing to help with special events.:  Yes  No   I am not able to commit to a project now.:  Yes  No   I would like to receive newsletters and info.:  Yes  No   My interests are:   Environment:  Yes  No   Child abuse/neglect:  Yes  No   Childhood Obesity:  Yes  No   Access to Health Care:  Yes  No   Senior Issues:  Yes  No   School Health:  Yes  No   Community Education:  Yes  No   Youth Issues:  Yes  No   Substance Abuse and Violence:  Yes  No   Access to Health Information:  Yes  No   Other Interests:   Please list special talents and abilities.: