LeadUS Mentoring Program 2015-16

New Member Agency Application
Date of Application*

MonthDayYear
Date
Agency Name*
What experiences, expertise, connections, or resources would your organization bring to BHCC? *
Does your organization serve a specific group of people? (e.g. offers support groups for LGBTQIA+ folks, an organization created to provide service to people without insurance, etc)*

YesNo
What population(s)?

People experiencing homelessnessUninsured or underinsured peopleImmigrantsLGBTQIA+ peopleOlder adultsDisabled peopleOther
Other
Provide a person that BHCC should contact to follow up with about this application. This person may or may not be who your organization would select to be the primary representative for the council.
Name of Agency Contact*
Title of Agency Contact*
Agency Contact Email*
Behavioral Health Coordinating Council Bylaws
I have read the BHCC Bylaws and understand the expectations for member organizatons.*

Yes
If my organization is not selected for membership, we still wish to be contacted in the event that BHCC needs additional expertise related to our types of services.*

YesNo
Should be Empty:

New Member Agency Application