Fill out the form below to become a member
of HEAT.
Full Name:
HOME Address:
HOME City/State/Zip
HOSPITAL Name:
HOSPITAL Address:
HOSPITAL City/State/Zip:
Email Address:
Phone:
Fax:
Position Title:
Key Contacts:
Having key contacts is a very important element of the HEAT grassroots program. HEAT Keys are individuals who already have well established relationships with their legislators and are willing to contact those legislators when needed on important issues. If you would be willing to serve as a HEAT Key Contact, please indicate this below and include the legislator’s name and the type of relationship you have with him/her (e.g., friend, neighbor, professional relationship, went to school together, etc.).
Yes, I
want to serve as a HEAT Key Contact
I have the following relationships with these legislators (please
provide name(s) and describe relationship(s).
Legislator Name:
Relationship:
Legislator Name:
Relationship:
Legislator Name:
Relationship:
Other Hospital Groups / Affiliations:
Are you a member of W-ONE (nurse executives)?
Are you a member of WSHHRA (human resources)?
Are you a member of WHPRMS (public relations)?
Are you a member of WHFMA (financing)?
Are you a member of Partners of WHA (volunteer or auxilian)?
