Membership Application
Demographics
Name
First Name
Last Name
Email
example@example.com
Mailing Address -or- City and County
Credentials (if applicable)
Areas of expertise (select all that apply)
Clinician
Service Provider (i.e. caregiver, fitness instructor, home health equipment company, etc.)
Administrator
Researcher
Community Member
Family Member
Other
Organization or Individual
Are you joining the Coalition as an individual or as a representative of an organization?
Organization
Individual
Organization Information
Organization Name
Organization Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organization Website
Your Role Within the Organization
Type of Organization
For-Profit
Non-Profit
Type of For-Profit Organization
Please Select
Hospital
Clinic
Rehab
Pharmacy
Insurance
Fitness
Mental Health
Social Service
Information Technology
Funding Agency
Policy Maker
Research and/or Development
Other (please describe below)
If Other, please describe here
Type of Non-Profit Organization
Please Select
Hospital
Clinic
Rehab
Pharmacy
Insurance
Fitness
Mental Health
Social Services
Information Technology
Funding Agency
Policy Maker
Researcher and/or Developer
State
County
City
Other (please describe below)
If Other, please describe here
How does your organization promote fall prevention efforts?
Does your organization currently offer any evidence-based fall prevention programming or services?
Yes
No
Is it offered to the public?
Yes
No
Is there a charge for the programming and/or service?
Yes
No
Please provide a description and a website or phone number to access the of the programming or service.
If not, who is it for?
If more than one program or service is available, please list them here and indicate who they are offered to, if there is a charge, and and how to contact them.
Does your organization offer other programming and/or services related to fall prevention in older adults?
Yes
No
Is it offered to the public?
Yes
No
Is there a charge for the programming and/or service?
Yes
No
Please provide a description and a website or phone number to access the of the programming or service.
If not, who is it for?
If more than one program or service is available, please list them here and indicate who they are offered to, if there is a charge, and and how to contact them.
Individual Information
Do you as an individual offer evidence-based fall prevention programming or services?
Yes
No
Is it offered to the public?
Yes
No
Is there a charge for the programming and/or service?
Yes
No
Please provide a description and a website or phone number to access the of the programming or service.
If not, who is it for?
If more than one program or service is available, please list them here and indicate who they are offered to, if there is a charge, and and how to contact them.
Do you as an individual offer other programming and/or services related to fall prevention in older adults?
Yes
No
Is it offered to the public?
Yes
No
Is there a charge for the programming and/or service?
Yes
No
Please provide a description and a website or phone number to access the of the programming or service.
If not, who is it for?
If more than one program or service is available, please list them here and indicate who they are offered to, if there is a charge, and and how to contact them.
Other Information
How else do you as an individual support fall prevention efforts? (i.e. talk to friends about fall prevention, etc.)
What other professional organizations do you belong to that could be potential allies for the Coalition? (i.e. Emergency Nurses Association, American Physical Therapy Association, American Geriatrics Society, Alzheimer's Association, non-profit groups, advocacy groups, etc.)
What else would you like the Coalition to know about you as a potential member?
Submit
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