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MCSHC Membership Agreement
Missouri Coordinated School Health Coalition Membership Agreement.
Are you completing this application as:
(Required)
an Organization
an Individual
Organization Name
(Required)
Person Completing Application
(Required)
First
Last
Title/Role of Person Completing Application
(Required)
Organization Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email of Person Completing Application
(Required)
Organizational Website
Contact Phone Number
(Required)
We agree to support the Vision, Mission and Core Values of the Missouri Coordinated School Health Coalition (MCSHC). We pledge to contribute time, resources, and expertise to actively support the mission of MCSHC in the following ways (mark all that apply):
(Required)
Health Education
Physical Education & Physical Activity
Health Services
Nutrition Environment & Services
Counseling, Psychological & Social Services
Social and Emotional Climate
Healthy School Environment
Health Promotion for Staff
Family Engagement
Community Involvement
Do not know
Other not listed
We identify that our organization matches the following areas (see description for the WSCC Components):
(Required)
Promote and use the WSCC model as a guide for improving students’ health & their capacity to learn
Distribute, on behalf of the coalition, information about the work of MCSHC
Encourage additional individuals or organizations to join in MCSHC’s collaborative efforts
Provide support for MCSHC publications by contributing content, printing, distributing, and/or promoting
Provide resources for schools related to an area of focus
Other not listed
Select All
Name
(Required)
First
Last
Title
(Required)
Organization/Affiliation
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Contact Phone Number
(Required)
Email
(Required)
I agree to support the vision, mission and core values of the Missouri Coordinated School Health Coalition (MCSHC). I pledge to contribute time, resources, and expertise to actively support the mission of MCSHC in the following ways (mark all that apply):
(Required)
Promote and use the WSCC model as a guide for improving students’ health & their capacity to learn
Distribute, on behalf of the coalition, information about the work of MCSHC
Encourage additional individuals or organizations to join in MCSHC’s collaborative efforts
Provide support for MCSHC publications by contributing content, printing, distributing, and/or promoting
Provide resources for schools related to an area of focus
Other not listed
I identify myself as knowledgeable the following areas (see description for the WSCC components):
(Required)
Health Education
Physical Education & Physical Activity
Health Services
Nutrition Environment & Services
Counseling, Psychological & Social Services
Social and Emotional Climate
Healthy School Environment
Health Promotion for Staff
Family Engagement
Community Involvement
Do not know
Other not listed