Download WVPCA`s Advocate Sign Up form

 Become An Advocate For Your Community Health Center Sign up for advocate email updates Health Center Advocates receive emails about…  Health center advocacy efforts  Federal legislation affecting health centers  Calls to Action to communicate with elected officials Sign up online at www.capwiz.com/nachc/wv/home/ or fill out the form below Prefix (check one): Mr. Mrs. Ms. Dr. First Name: _____________________________________________________________________________________ Last Name: _____________________________________________________________________________________ Email (required): ________________________________________________________________________________ Home Address: _________________________________________________________________________________ City: __________________________________________________________ State: _______ Zip: ______________ You will not be contacted at home; however we do need this information so that we can accurately pair you with your elected officials. Phone: (______)_________________________________ Mobile: (______)________________________________ 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: ______________________________________________________________________________  I would like to receive the WVPCA’s weekly electronic newsletter via email. Send completed forms to: Fax: (304) 346‐0033, Attn: Advocate
Email: [email protected] This information is for WVPCA use only and will not be distributed outside the CapWiz advocacy 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 or the elected official with whom that member chooses to communicate without prior written consent.