Membership Application

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

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 allows any staff or volunteer from your organization to participate in meetings, leadership positions, and the website listserve. Individuals can also join.

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 above, 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.
Email
Agency email for public use, if applicable.
Website
Contact for annual invoicing, if different.
Email
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 (ListServe*) for members. Additional corporate member representatives can attend at any time and/or be added to the listserve by sending emails and contact information to info@cosaslc.org.

ListServe NOTE: No.reply@oneandone.com must be added to the address book of each individual to have acccess to the listserve to ensure that messages are not marked as spam and that the person will receive the double opt-in confirmation email. 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.
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
Add other contacts for the listserve here, if needed.
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 JUST INCLUDE YOUR URL.
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
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
Please upload a high-quality version of your logo for the website link. You may also upload any informational flyers or brochures.

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COSA MEMBERSHIP APPLICATION

Listserve & Attendees