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Athens Community Wellness Council

Membership Form

Name_________________________________________________________________

Organization____________________________________________________________

Title (if appropriate)______________________________________________________

Address_______________________________________________________________

City_____________________State_______________ZIP_______________________

Daytime Phone_________________________________

Evening Phone_________________________________

Email Address__________________________________________________________

I would like to be involved in the Wellness Council in the following capacity:

[] Serve on the Executive Committee (requires attendance of 4+ meetings per year)

[] Receive Exec Committee information (minutes, newsletters, etc), but I can not serve on the committee

[] Receive event notification only (luncheons, etc)

Comments:______________________________________________________________

_______________________________________________________________________

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