Interfaith Health Network Enrollment Form

Program Information

Thank you for your interest in participating in our faith-based organization partnership initiative. Please complete the information below to enroll your organization.

Section 1: Organization Information

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1. Organization Name (Required.)

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2. Denomination/ Faith Tradition (Required.)

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3. Type of Organization (Required.)

Church

Mosque

Synagogue

Temple

Faith-based Organization

Ministry

Other (please specify)

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4. Year established

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5. Tax-Exempt Status (Required.)

501(c)3

Non-profit

Not applicable

Other (please specify)

Section 2: Organization Demographics

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6. Physical Address (Required.)

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7. Mailing Address (If different)

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8. Main Phone Number (Required.)

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9. Organization Email Address (Required.)

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10. Website

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11. Social Media

Facebook

Instagram

Twitter/X

YouTube

Section 3: Congregation/ Community Demographics

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12. Average Weekly Attendance (Required.)

Fewer than 50

51 - 250

251 - 500

More than 500

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13. Age groups primarily served (check all that apply} (Required.)

Children

Youth/ Teenagers

Young Adults

Adults

Older Adults/ Seniors

Families

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14. Populations Served (check all that apply) (Required.)

General community

Low-Income Families

Individuals Experiencing Homelessness

Veterans

Individuals with Disabilities

Immigrant/ Refugee Communities

Communities of Color

Rural Communities

Other (please specify)

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15. Languages spoken in the congregation/ organization (Required.)

English

Spanish

Haitian Creole

Russian

Cantonese

Mandarin

French

Arabic

Urdu

Other (please specify)

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16. Community outreach programs offered (check all that apply) (Required.)

Food Programs

Health Ministry

Youth Programs

Counseling Services

Older Adult/ Senior Services

Educational Programs

Housing Assistance

Substance Use Recovery Support

Transportation Assistance

Other (please specify)

Section 4: Organization Point(s) of Contact

Primary Contact

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17. First Name (Required.)

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18. Last Name (Required.)

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19. Title/Role

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20. Phone Number (Required.)

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21. Email (Required.)

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22. Preferred Method of Contact (Required.)

Call

Text Message

Secondary Contact

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23. First Name

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24. Last Name

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25. Title/ Role

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26. Phone Number

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27. Email

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28. Preferred Method of Contact

Call

Text

Thank You!

Interfaith Health Network Enrollment Form

Question Title

* 1. Organization Name (Required.)

Question Title

* 2. Denomination/ Faith Tradition (Required.)

Question Title

* 3. Type of Organization (Required.)

Question Title

* 4. Year established

Question Title

* 5. Tax-Exempt Status (Required.)

Question Title

* 6. Physical Address (Required.)

Question Title

* 7. Mailing Address (If different)

Question Title

* 8. Main Phone Number (Required.)

Question Title

* 9. Organization Email Address (Required.)

Question Title

* 10. Website

Question Title

* 11. Social Media

Question Title

* 12. Average Weekly Attendance (Required.)

Question Title

* 13. Age groups primarily served (check all that apply} (Required.)

Question Title

* 14. Populations Served (check all that apply) (Required.)

Question Title

* 15. Languages spoken in the congregation/ organization (Required.)

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* 16. Community outreach programs offered (check all that apply) (Required.)

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* 17. First Name (Required.)

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* 18. Last Name (Required.)

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* 19. Title/Role

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* 20. Phone Number (Required.)

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* 21. Email (Required.)

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* 22. Preferred Method of Contact (Required.)

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* 23. First Name

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* 24. Last Name

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* 25. Title/ Role

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* 26. Phone Number

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* 27. Email

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* 28. Preferred Method of Contact

1. Organization Name (Required.)

2. Denomination/ Faith Tradition (Required.)

3. Type of Organization (Required.)

4. Year established

5. Tax-Exempt Status (Required.)

6. Physical Address (Required.)

7. Mailing Address (If different)

8. Main Phone Number (Required.)

9. Organization Email Address (Required.)

10. Website

11. Social Media

12. Average Weekly Attendance (Required.)

13. Age groups primarily served (check all that apply} (Required.)

14. Populations Served (check all that apply) (Required.)

15. Languages spoken in the congregation/ organization (Required.)

16. Community outreach programs offered (check all that apply) (Required.)

17. First Name (Required.)

18. Last Name (Required.)

19. Title/Role

20. Phone Number (Required.)

21. Email (Required.)

22. Preferred Method of Contact (Required.)

23. First Name

24. Last Name

25. Title/ Role

26. Phone Number

27. Email

28. Preferred Method of Contact