Minnesota Health Literacy Partnership | Minnesota Health Literacy Partnership (MHLP) Membership Agreement

Today's Date: *

Organization Name as it should appear on MHLP materials:

if joining as an individual, this field is not required

Agreements

Meeting Attendance: *

We understand that members are expected to attend meetings and participate actively in the work of MHLP

Participation: *

We understand that the benefits of membership include networking opportunities, educational meetings, and shared resources. We also understand that our paid membership entitles us to vote on the business of MHLP (one vote per organization) and to participate fully in its governance.

Our representative at MHLP meetings will be:

Representative Name: *

Representative Department and Title: *

Representative Mailing Address: *

Representative Phone number: *

Representative Email: *

Please provide us with information about you and/or your organization

Brief description of company: *

Permission to use this on MHLP website: *

Granted

Denied

Share a brief statement about why you/your organization are interesting in joining MHLP: *

Permission to use this statement on MHLP materials: *

Granted

Denied

List any current activities your organization is doing around health literacy: *

Permission to use this information on MHLP materials: *

Granted

Denied

Upload Logo:

If you prefer to email your logo, please email to Alisha Ellwood

Permission to use your logo on MHLP website: *

Granted

Denied

Membership Dues

As a requirement of membership, we agree to pay: *

$50.00 - Individuals

$100.00 - Organizations with an annual budget of less than $500,000

$250.00 - Organizations with an annual budget between $500,000 and $5 million

$500.00 - Organizations with an annual budget of more than $5 million

Payment: *

I am mailing a check to Minnesota Health Literacy Partnership (MHLP) for membership dues.

Please invoice us for our Minnesota Health Literacy Partnership (MHLP) membership dues.

Mail Invoice to:

Same as address above

The address below

Send invoice to

Contact Name:

Organization Name:

Mailing address:

Billing instructions if applicable:

Make all checks payable to: Minnesota Literacy Council
Mail payment to: Minnesota Literacy Council, 700 Raymond Ave, Suite 180, St. Paul, MN 55114

The Minnesota Literacy Council (MLC) will send you an invoice upon receipt of your membership agreement. Please be sure that the contact information is accurate and current.

By submitting this form, we agree to the terms specified above.

, MA, LMFT
Project Manager, Health Care Improvement
Blue Cross and Blue Shield of Minnesota
Ph: 651-662-0986