MARTIN COUNTY HEALTHY START COALITION
MEMBERSHIP FORM

Martin County Healthy Start Coalition, Inc. is a 501c3 organization operating under a Board of Directors. The mission of Martin County Healthy Start is to ensure that all babies in Martin County are born healthy. The Coalition relies on members from the community to help set priorities to meet local needs in maternal and infant health.

Name: _ Title: _
Organization (if applicable): _
Mailing Address:
City: _State: Zip:
Phone _ Fax
E-mail_
If you are representing an agency, please provide its mission:

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I am interested in supporting the Coalition in the following areas:
 Participating in special Coalition activities; health fairs, educational events, presentations
 Serving on a Healthy Start speaker’s bureau
 Attending Coalition planning meetings
 Other
Please list any other membership or board affiliations:

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 I am the designated voting member of the Martin County Healthy Start Coalition, Inc. representing my agency.
Signature Date __