Impact York County Member Commitment Pledge

Impact York County Member Commitment Pledge

Please complete the following information.
As a member of Impact York County, it is my privilege to make this commitment to work with leaders from other organizations and institutions to improve health outcomes in York County under the umbrella of the Impact York County coalition. As a part of this alliance, I commit to:

1.)    Supporting the development and implementation of a health improvement plan (“Impact York County: County Health Improvement Plan”) focused on improving the health and well-being of every person in York County; and taking an active role in guiding and supporting the plan within my organization/institution and across other organizations and sectors;

2.)    Ensuring that Impact York County’s collective improvement work is conducted through an equity lens with priority actions and solutions for communities and populations most at risk for poor health and well-being;

3.)    Accepting and supporting a common set of health improvement priorities and measurable goals for Impact York County;

4.)    Adopting the guiding principles and practices of Impact York County’s Evidence-Based Intervention(s) as the platform for development and implementation;

5.)    Aligning specific population health improvement initiatives conducted by my organization/institution, as feasible, in support of Impact York County’s health improvement work;

6.)    Providing representation and making available appropriate staff and resources from my organization at Impact York County meetings and activities, including serving on Impact York County committees or workgroups, as feasible;

7.)    Participating in collaborative data collection, and sharing aggregate, anonymous data, as feasible, in support of actively measuring and monitoring Impact York County’s collective health improvement priorities and measurable goals;

8.)    Supporting the pursuit of funding and other needed resources on the behalf of Impact York County, as approved by Impact York County;

9.)    Communicating information about the activities of Impact York County to the community and partners;

10.) Allowing my name and that of my organization/institution to be included in Impact York County communications and on the membership roster;

11.) Creating a healthy environment for attendees of Impact York County programs and events which includes adopting healthy meeting guidelines developed by the National Alliance for Nutrition and Activity;

12.) Demonstrating a culture of health and wellness.

So we can better understand how Impact York County can work with you to help achieve our mutual goals, we ask:
12.) Please describe how Impact York County can meet the needs of your organization/institution. *
13.) What health outcomes matter to you and your organization/institution? *
14.) Who are your populations of interest? (e.g., age, race/ethnicity,geography) *
COMMUNITY GUEST MEMBER

If you are joining as an individual community member, please enter your full name. You may list Not Applicable to any required field that doesn't apply to you. Communty Guest Members are welcome to attend all meetings however they do not hold coalition voting privileges.
Guest Membership - Full Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
COALITION MEMBERSHIP REQUEST

If you are representing more than one organization or coalition through Impact York County, please submit a separate application for each one.
15.) Organization Name *
Organization Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Organization Website *
Primary Contact Name *

First Name Last Name
Primary Contact Phone *

Area Code Phone Number
Primary Contact Email *
example@example.com
Signature of Applicant *

Clear
Date Submitted *

Month Day Year
Date
Please verify that you are human *
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