Membership is open to all individuals and organizations in sympathy with the Friend’s mission and purpose.

Name: (Please print.)  ___________________________________________________ 

Email: _____________________________________________________________

Phone Numbers:   Home: ______________      Work: ______________ ext:_______

Cell: ____________ Fax: ______________

Mailing Address: ______________________________________________________

City:__________________________     State:______________     Zip:___________

Would you be willing to serve on one of the following committees as a chair or worker? 

Check those you are interested in:

* Membership Committee

* Development/Fundraising Committee

* Communication Committee

* Public Education Committee

* Advocacy Committee

Are you interested in serving on the board?

  * Yes     * No Thanks        

 Please list your special skills or areas of expertise? 

_______________________________________________________________________

_______________________________________________________________________ 

Enclosed Membership Fees: 

* $15/yr Individual 

* $25/yr Family 

* $50/yr Business/Organization

 o I wish to donate $__________ enclosed for public health services.

“I support the mission and purpose of Coos County Friends of Public Health”

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Signature                                                                              Date