GVPHC Membership Enrollment
My Agency wants to join The GVPHC!
Agency Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Agency Type
*
Please Select
Law Enforcement
Hospital(s)
Mental Health Service Organizations
Substance Abuse Service Organizations
Affordable Housing Developer(s)
Public Housing Authorities
Youth Homeless Organizations
School Administrators/Homeless Liaisons
Victim Service Providers
Human Trafficking Survivor Services Agencies
Homeless or Formerly Homeless Person(s)
Street Outreach Team(s)
HIV/AIDS Community Advocates and Service Providers
Elderly and Disables Advocates and Service Providers
Veterans Homeless Service Providers
Nonprofit Homeless Service Providers
Faith-Based Organizations
Concerned Citizen(s)
Local Government Staff/Official(s)
Other
Executive Director's Name
*
First Name
Last Name
Email
*
example@example.com
Additional Agency Contact's Name
*
First Name
Last Name
Email
*
example@example.com
I acknowledge that for the above agency to be considered an active GVPHC member, at least one delegate being in the executive or managerial positions, must meet the Bylaws definition of active membership (see Article III).
*
Electronic Signature: By entering your name above, you acknowledge that all of the above information is true and accurate.
Clear
Date
*
-
Month
-
Day
Year
Submit
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