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Thank you for your interest and participation in Civitas Networks for Health. We appreciate you taking the time to thoroughly complete the information below to help us best understand your organization's structure, priorities, mission, and goals for participating in the network.

Whether you are looking to join Civitas as a new member, or are a longstanding member, we request that you answer all questions as thoroughly as possible. We will also request annual updates and all members must accept the terms and conditions and code of conduct, and contribute annual dues established by the Civitas Board of Directors.

The form uses logic and may prompt additional questions based on your selected response. If you have questions, please email contact@civitasforhealth.org.

Organizational Information
Please provide the following information for your organization.

President/Chief Executive Officer/Executive Director Contact
Please provide information for the organization's CEO/Executive Director and Executive Assistant, or related contact.

Organization Structure and Size
Please provide information on the structure and size of your organization.

Expertise and Strategic Priorities

In order to best serve our members, it is important that we understand your organizational areas of expertise and strategic priorities. We also recognize that priorities change and will request updates annually.

Membership Terms and Conditions and Code of Conduct

Civitas prides itself on delivering benefits that provide members an opportunity to engage, network, and collaborate. To support opportunities for safe and open discussion, all members must adhere to Membership Terms and Conditions and Code of Conduct.

Terms and Conditions and Code of Conduct*
By submitting this form and completing the signature page, I am acknowledging that I am an authorized representative of my organization to review and accept the Membership Terms and Conditions and Code of Conduct for Civitas Networks for Health.