CHSCPR Application Form: At Large Member – Executive Committee My employer is in support of my participation: * Yes No Name: * Pertinent Credentials: * Organization: * Email: * Please indicate the committee or workgroup you have been a member of in the last year: * Executive Committee Information Sharing Medical Surge Responder Safety and Health Training and Exercise Please indicate the number of All Partners meetings you attended in the past year: * 1-2 3-4 More than 4 I will support the Emergency Operations Plan of the Coalition and complete the program outcome objectives as detailed in the grant application and annual work plan: * Yes No Submit Start Over If you are human, leave this field blank.