Organization Application

COMMUNITY PARTNER ORGANIZATION APPLICATION

To qualify as a COPE Community Health and Wellness Volunteer, please read the eligibility criteria on our COPE Website and complete all the information requested in this form.

Organization Name

Organization Address

Contact Details of Appointed CCHW Champion

Contact Name

Role in Organization

Phone

Contact Details of CCHW Appointed Ambassador?

Contact Name

Phone

What organizatin membership level are you applying for?

Gold

Silver

How many employees do you have?

How many hours per week will your organization commit to this campaign?

Do you currently have a Health & Wellness Program?

When can you join the campaign?

How will this campaign be of benefit to your organization?

Please us this space to describe how your organization will: 1) Keep employee informed of health literacy information. 2) Keep people trained and certified on Stroke Awareness, Stop the Bleed, Hands Only CPR and AED. 3) Collect Data to show health and wellness improvements. 4) Monitor and maintain AEDS and First Aid Kits. 5) Work to improve health and wellness of employees.

How did you hear about the CCHW Program?

Training sessions and Zoom presentations by guest speakers will be recorded so that we can share them publicly. You may appear in these recordings although we will edit out any Q&A that take place during these sessions. Additionally, we may take photographs or video recordings at in-person gatherings for use in promotional materials.

By checking the box below, you agree to participate in these recordings and give permission and agree to allow us to use your name and/or image in our materials.

I agree!

Your Signature

Date

Thank you! We’ll be in touch.