Organizations Application

The National Forum for Heart Disease & Stroke Prevention

NATIONAL FORUM MEMBERSHIP APPLICATION FOR ORGANIZATIONS

Zip: Country:

This application for Organizational Membership provides background information about the organization applying for membership in the National Forum for Heart Disease and Stroke Prevention, and the voting delegate from that organization. Additional non-voting delegates may be appointed by the organization by completing the Organizational Delegate Application Form. The information in this form will be used to best align the interest, expertise and skills of the organization and its delegates with the work of the National Forum and its Implementation Groups and Committees.

Zip:

Country: Fax: Telephone:

E-mail: State: Address:

Organization Name: Title: City: Address (cont):

Address (cont):

Address: Telephone:

Fax:

Organization Website:

Primary Organizational Representative To The National Forum

This Person will serve as the organizations voting delegate.

City:

Email: State:

Staff Assistant Information (if applicable):

Name:

Skills & Expertise:

Name: Which of the following best describes your organization? (select one) What areas of skill and expertise does your organization possess relative to heart disease and stroke prevention? (check all that apply) Data collection, analysis and surveillance
Health program planning and implementation
Health promotion/education
Policy assessment and/or development
Health care delivery
Medical care quality assessment and improvement
Legislative advocacy
Health program evaluation
Other ("Please Decribe Below")

Organization Type:

Brief description of the mission, purpose, and scope of work of your organization (100 words or less):

Mission, Purpose, and Scope:

Brief description of how the mission and goals of your organization relate directly to heart disease and stroke prevention, and how your organization's involvement in the National Forum will contribute to the implementation of A Public Health Action Plan to Prevent Heart Disease and Stroke (150 words or less):

Scope of Work/National Action Plan:

**To complete your application, send your curriculum vitae or resume to fberrier@danya.com If you have any questions, Faith can be reach at 404/604-2729. Please remember to click the Submit button.**