AUCH Affiliate Membership Application

Affiliate Membership is available to non-profit providers of direct primary and preventive healthcare services. Affiliate Member benefits include in-person and web-based training and technical assistance, quarterly summits, virtual and in-person peer group meetings, and direct organization assistance. AUCH supports Affiliate Members in quality improvement and the delivery of high-quality primary and preventative healthcare to Utah’s medically underserved populations. Please submit this application, along with required dues, to AUCH.

Your Name(Required)

Organization Information

Organization Name(Required)
Organization Address(Required)
Executive Director / CEO Name(Required)

Statement of Collaboration

On behalf of, and with full consent of the Board of Directors of
I understand and agree, as a term of affiliate membership in the Association for Utah Community Health, that the organization stated above will at all times operate in a manner which is consistent with AUCH’s mission, goals, objectives, and implementing policies.

Signature

By entering your name here as your signature, you agree to the terms stated in the Statement of Collaboration.
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Required Documentation (Upload Files)

*As a condition of affiliate membership, please submit the following documentation:
Max. file size: 64 MB.
General overview of your organization or your organization’s most recent annual report.
Max. file size: 64 MB.
Current list of administrative and key staff members (MUST INCLUDE name, title, email address)
Max. file size: 64 MB.
MUST INCLUDE member contact list, election and board meeting dates
Please download organizational information form, fill it out and upload below.
Max. file size: 64 MB.
Please download the above form, fill out, and upload here.