Download Become a Grassroots Advocate for Your Community Health Center

Become a Grassroots Advocate for Your Community Health Center
Sign up for email updates
Health Center Advocates receive emails about…
 Health Center advocacy efforts
 Federal and state legislation affecting Health Centers
 Calls to Action to communicate with elected officials
Sign up online at www.ohiochc.org/advocate or fill out the below form.
Prefix (circle one): Mr. Mrs. Ms. Dr.
First Name:___________________________________________________________
Last Name:___________________________________________________________
EMAIL:_______________________________________________________________
Home Address:__________________________________City:______________Zip:________
You will not be contacted at home; however we do need this information
so we can accurately pair you with your state and federal elected officials
Phone:_______________________________________________________________
Write in name of Health Center:___________________________________________
Please check all that apply:
� I am a health center patient
� I am a health center board member
� I am health center staff. Position:____________________________________
� Other supporter:_________________________________________________
Send completed forms to the Ohio Association of Community Health Centers:
FAX: (614) 884-3108
Email: [email protected]
Mail: 4150 Indianola Avenue, Columbus, Ohio 43214
This information is for OACHC and NACHC use only and will not be distributed outside the CapWiz system. CapWiz will not use, or
allow any other party to use personal or member data except as needed to implement the CapWiz system. Further, CapWiz will
never sell, lease, loan or in any way share personal or member data with another party except the member him/herself, the elected
official with whom that member chooses to communicate, or OACHC without prior written consent.