Organizational Information
Please provide the following information for your organization.














Contact Information

  • President/CEO/Executive Director: The primary leader of the organization, responsible for overall strategic direction, decision-making, and organizational management.
  • Executive Assistant: Provides administrative and operational support to the President/CEO/Executive Director and the organization, ensuring smooth coordination of leadership tasks and initiatives.
  • Primary Contact: Serves as the main liaison for membership-related communications between the organization and the Civitas team, managing all inquiries, updates, and relevant information.
  • Finance Contact: Oversees financial transactions, including processing invoices and handling finance-related matters on behalf of the organization, ensuring timely and accurate financial management.

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





Primary Contact






Financial Contact






Additional 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.




Contact Information