This page may not work correctly in your current browser, Internet Explorer. We recommend changing to a more modern browser before viewing this page. We recommend Chrome, Firefox, Safari, or Edge. Organizational Membership Application Please choose the appropriate tier and 330h grant amount or homeless services budget below. The dues amount associated with each level is listed at the end. Membership Level: Tier 1 - under $500,000 - $575 Tier 1 - $500,001 - $1,000,000 - $1,150 Tier 1 - $1,000,001 - $1,500,000 - $1,725 Tier 1 - $1,500,001 - $2,000,000 - $2,300 Tier 1 - $2,000,001 - $2,500,000 - $2,875 Tier 1 - $2,500,001 - $3,000,000 - $3,450 Tier 1 - $3,000,0001 - $4,000,000 - $4,025 Tier 1 - $4,000,001 - $5,000,000 - $4,600 Tier 1 - Greater than $5,000,000 - $5,175 Tier 2 - Less than $500,000 - $575 Tier 2 - $500,001 - $1,000,000 - $650 Tier 2 - $1,000,001 - $1,500,000 - $975 Tier 2 - $1,500,000 - $2,000,000 - $1,300 Tier 2 - $2,000,001 - $2,500,000 - $1,625 Tier 2 - $2,500,001 - $3,000,000 - $1,950 Tier 2 - $3,000,000 - $4,000,000 - $2,600 Tier 2 - $4,000,001 - $5,000,000 - $3,250 Tier 2 - Greater than $5,000,000 - $3,900 Tier 3 - Less than or equal to $3,000,000 - $575 Tier 3 - $3,000,001 - $5,000,000 - $800 Tier 3 - Greater than $5,000,000 - $1,200 Tier 4 - First Time Members - $500 Organization Information: Organization Name: Organization Type: Federally-funded Health Care for the Homeless Project (Receives a Section 330h grant) Federally-funded Community Health Center (Receives a Section 330e grant) Community Health Center Providing Homeless Health Services Medical Respite/Recuperative Care Program Hospital Primary Care Association Non-Profit providing non-health services for people experiencing homelessness Government entity providing non-health services for people experiencing homelessness Advocacy Organization Continuum of Care Other Alternate/DBA/HRSA Organization Name: Address: Address Line 2 City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia 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 Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Phone: Zip: - Zip Suffix Organization Official Representative Information: The representative serves on the Governing Membership of the National Health Care for the Homeless Council and is also the contact person for all Council business. Representative First Name: Representative Last Name: Job Title: Email: Alternate Representative Information: If your Organizational Representative is unreachable, who may we contact? Alternate Representative First Name: Alternate Representative Last Name: Alternate Representative Title: Alternate Representative Email: How did you hear about the Council? Source Word of Mouth Internet Search E-Blast/Council Publication Social Media (Facebook/Twitter/LinkedIn) Newspaper/Magazine Article Television/Radio Webinar Participant Conference I have been familiar with the Council for a while Other Neon CRM by Neon One Join the Council Make A Donation Contact Us Our Networks Respite Care Providers' Network National Consumer Advisory Board HCH Clinicians' Network Get Involved Join Our Organization Donate to Our Cause This website is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $1,625,741 with 20 percent financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov. Copyright © 2021 National Health Care for the Homeless Council, Inc. PO Box 60427 | Nashville, TN 37206 | (615) 226-2292 Disclaimers and Payment Policies FollowFollowFollow
