Join WHA’s HEAT Advocacy Network

Full Name: 
HOME Address: 
HOME City/State/Zip: 
HOSPITAL Address: 
HOSPITAL City/State/Zip: 
Email Address: 
Phone (with area code): 
Fax (with area code): 
Position Title: 
Referred By: 
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 legislators 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:
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 (finance)?
Are you a member of Partners of WHA (volunteer or auxilian)?
Are you a member of WADVS (directors, volunteer services)?