CASBHC Membership Application

Name
Title
Organization
Address
City		State		Zip
Phone
E-mail

 

Sponsoring Organization Membership
A sponsoring organization is an owner or a primary sponsor of an operational school-based health center. Membership dues are based upon the organization's budget. Please call CASBHC at 303-399-6380 for further information.
Collaborating Organization Membership
A collaborating organization has a contractual affiliation with an operational school-based health center to provide patient care or other direct services.
	Collaborating Organization	$100.00
Associate Memberships
An associate member is an organization or individual supportive of the mission and goals of CASBHC.
	Associate Organization	$100.00
	Individual	$ 35.00
Other Contributions
	Donation	$_____.____
Total		$_____.____
Please make checks payable to CASBHC and mail with application: CASBHC  1750 High Street Denver CO 80218