COSA Membership Application

COSA MEMBERSHIP APPLICATION
The Council of Social Agencies is a networking group that serves to educate and promote communication, collaboration, cooperation, and coordination among member health and human service agencies and individuals to more effectivley serve residents.

Membership in COSA is open to any agency, firm, foundation, organization, or individual concerned with health and human services for residents in our area. A Corporate membership ($40) allows any staff or volunteers from your organization to participate in meetings, leadership positions, and the website listserve. Individuals can also join ($20).

Membership runs from January to December. We ask that you complete this application each year to ensure information is kept current. For exisiting members, if you are not sure who is currently on the listserve for your organization, email and request an update.

For more information on the benefits of membership visit www.cosaslc.org/Benefits.html.
Membership Status*
Please select renewal or new.
If you are a new member, how did you find out about COSA?*

N/A (existing or prior member)Search Engine (e.g., google, yahoo, etc.)Recommended by friend/colleagueSocial MediaEventOther
If you selected 'Other', please identify how you learned about COSA.
Type of Membership*
Please select corporate or individual.
Organization/Individual Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number for use by the public.
Email
Agency email for public use, if applicable.
Website, if any.
Contact for annual invoicing, if different.
Email
I will pay:*

by check to COSA, PO Box 2356, Fort Pierce, FL 34954.by credit card at www.cosaslc.org using the form on the homepage.
Listserve & Attendees

This section is strictly for listserve updates and COSA record keeping. Information entered here will NOT be shared directly with other members. Instead, members are encouraged to use the listserve to communicate or to obtain individual contact info directly from others.
Below, please add specific contact information for individual(s) who will be attending meetings and COSA events, and/or who shoud be added to the email distrbution list (aka., ListServe) for members. Additions will not be completed until membership fees have been received.

Additional corporate member representatives can attend at any time and/or be added to the listserve by sending name, email address, and contact information to info@cosaslc.org.

NOTE: Please inform those being added to the listserve that they must add No.reply@oneandone.com to their address book to ensure that messages are received. The system uses a double opt-in process where the individual will be sent an email that contains a confirmation link that MUST be used to ensure they are added. If the confirmation link in that email is not used, the person will not be able to send to the list.

*A ListServe is a tool for communicating with a group of people via email (i.e. discussion group). One email message is sent to the "reflector" email address (listserve@cosaslc.org), and the software then sends the email to all of the group's members. More info

Please notify us as soon as possible about members that LEAVE your organization, so they can be removed from the listerve. Thank you!
Primary Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Phone type

OfficeMobile
Email*
example@example.com
Name 2, if applicable.

First NameLast Name
Phone Number
Please enter a valid phone number.
Phone type

OfficeMobile
Email
example@example.com
Name 3, if applicable.

First NameLast Name
Phone Number
Please enter a valid phone number.
Phone Number Type

OfficeMobile
Email
example@example.com
If needed, add other contacts for the listserve here with the same information requested above (Name, phone, email).
Please indicate the sub-committee(s) upon which you or other representatives would like to serve, if any.

Community/Public RelationsEvent PlanningMembership
Provide a short description of your organization and services for the COSA website. (2-3 sentences ONLY!). *
Please DO NOT cut and paste paragraphs of information OR include only a URL.
Please upload a high-quality version of your logo for the website link. You may also upload any informational flyers or brochures.

Cancelof
I have the authority to approve the addition of my organization's website URL to the COSA website and my signature signifies consent to do so.
Signature*

Clear
Printed Name*

First NameLast Name
Date*

MonthDayYear
Should be Empty:

COSA MEMBERSHIP APPLICATION

Listserve & Attendees