Connections Membership Application

Membership Application
Connections Community of Practice

To register as a Stakeholder or Project member of the Connections Community of Practice, please provide us the following contact information.

Contact Information

First Name:
Last Name:
Title:
Organization:
Address 1:
Address 2:
City:
State:
Postal code:
Phone Number:
Email Address:

I am registering as a:
Stakeholder Stakeholders are those individuals/organizations that wish to be informed of Connection’s activities, and receive invitations to participate in activities. Stakeholders are able to participate in any community activity, however they are not required to participate in workgroups or provide written project plans. Project Member Project Members are expected to participate in workgroups, site visits, and other community activities and contribute to product development. In addition to the registration form, project members will complete the Project Brief form and Project Readiness Assessment documents. Please indicate a category State or Local Health Department Healthcare Social Service Agency Other (please specify)

The Public Health Informatics Institute is the convener of the Connections Community of Practice. The Institute will use this information to send you information about Connections Community of Practice activities as well as keep you informed on issues to integration of child health information systems.

For more information
For questions or assistance with registration, contact Jim Mootrey at JMootrey@phii.org
Phone: 404-592-1416
Fax: 404-371-0415