Network Member Application

General Information
Organization Name
Address
Address (cont.)
City
State
ZIP
Telephone
Fax
Website
Director Information
Director Name
Title
Email Address
Network Information
Year Organized
Budget Size
Mission
Purpose
Programs
No. Members
Location of Members
Verification Code Please enter the letters that appear in the box to the right.

Membership dues are billed annually.
You will be invoiced the prorated amount for this year.

Mission: to support and strengthen health alliances through
collaboration, networking, leadership development, and education.

400 S. Main Street
Hardinsburg, Kentucky 40143
Ph: 270-925-5611