Healthiest Manitowoc County | Request to Join Steering Committee

Steering Committee Membership Request

Date *

First and Last Name *

Phone Number *

Email Address *

Which organization do you represent? (Ex: Company name, community member, etc) *

Have you been on the Steering Committee before? *

Yes

Which HMC coalition(s) are you currently involved in? Please select all that apply *

Investing Early

Youth Engagement

Substance Abuse and Mental Health

Physical Activity and Nutrition

Access to Health Services

Worksite Wellness

I am not currently involved in any coalitions

Please briefly describe why you want to be a member of the HMC's Steering Committee *