National Health Care for the Homeless Council

	Housing and Health Care are Human Rights
APPLICATION FOR ORGANIZATIONAL MEMBERSHIP

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For Calendar 2010, annual dues range from $500 to $3,500 based on the amount of the organization's federal Health Care for the Homeless grant or contract, or the budget of its Respite Care program Dues amounts are negotiated for other types of organizations. For all new members, an introductory rate of $500 is charged for the first year. The National Council pro-rates dues payments for partial year memberships and will send dues invoices when organizations are accepted for membership. To initiate the application process, please complete and submit the following:



This organization supports the mission of the National Health Care for the Homeless Council and wishes to become an Organizational Member. Please contact me.
Organization Name: *
Contact Name *
Position *
Address *
City *
State *
Zip *
Telephone *
E-mail *
This organization is (check all that apply): *	a Federally funded Health Care for the Homeless (HCH) project (receives a Section 330(h) grant) a federally funded Community Health Center (CHC) (receives a Section 330(e) grant). a subcontractor or subrecipient of an HCH or CHC grantee a Medical Respite Care provider Other

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If you prefer, you may print this form and send it to:
National Health Care for the Homeless Council
PO Box 60427
Nashville TN 37206-0427
615-226-1656 (fax)