Please describe yourself.
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I am interested in joining one of the Connections IN Health initiatives/coalitions
I am CURRENTLY a member of at least one of the Connections IN Health initiatives/coalitions
I am only interested in receiving more information about the Connections IN Health initiatives/coalitions
First Name
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Last Name
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Organization
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Position
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County Served
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Statewide Multiple Adams Allen Bartholomew Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawford Daviess Dearborn Decatur DeKalb Delaware Dubois Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko LaGrange Lake LaPorte Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush Scott Shelby Spencer St. Joseph Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley
Please select 'Multiple' if you serve more than one county
Please list all counties served
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Email Address
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AL AK AS AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY
Can we contact you via text?
Yes
No
Which initiative(s) are you interested in joining?
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Cancer Control Initiatives
Cardiovascular and Diabetes Coalition of Indiana (CADI)
Hoosier Health and Wellness Alliance (HHWA)
Indiana Joint Asthma Coalition (InJAC)
Which initative(s) are you a member of?
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Cancer Control Initatives
Cardiovascular and Diabetes Coalition of Indiana (CADI)
Hoosier Health and Wellness Alliance (HHWA)
Indiana Joint Asthma Coalition (InJAC)
Which Connections IN Health initiative(s) would you like more information for?
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Cancer Control Initiatives
Cardiovascular and Diabetes Coalition of Indiana (CADI)
Hoosier Health and Wellness Alliance (HHWA)
Indiana Joint Asthma Coalition (InJAC)
Connections IN Health in general
The Cancer Control Outreach initiative collaborates with the IU Simon Comprehensive Cancer Center’s Community Outreach and Engagement Office, as they strive to increase awareness of cancer as a cause of suffering and death, disseminate evidence and community-based cancer control strategies that focus on eliminating cancer disparities and promoting health policy to decrease the cancer burden in Indiana.
Select the membership level that you best identify with.
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General Membership - General Members receive general and periodic information from the initiative via email or social media.
Active Membership - Active Members are interested in meeting on a quarterly basis to receive updates on tobacco control, colorectal, and other cancer initiatives.
The Cardiovascular and Diabetes Coalition of Indiana (CADI) is working to help Hoosiers address the burden of cardiovascular diseases, diabetes, and stroke through education, collaboration, awareness, advocacy, and access to care. CADI uses its long-standing history of engaging various partners throughout the state in service of this work. The coalition has successfully been able to develop and launch the Better Together Plan, Indiana’s first statewide strategic plan to address cardiovascular disease, diabetes and stroke together. Learn more here .
Select the membership level that you best identify with.
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General Membership (Entry Level) - General Members receive general information and periodic information from the coalition via email or social media.
Partner Membership (Mid-Level) - Partner Members actively attend coalition meetings, participate in discussion around coalition activity and direction in addition to the previous level.
Active Membership (High Level) - Active Members participate in the coalition workgroups, which seek to engage in coalition activities that propel the current strategic direction that has been approved by the coalition in addition to the previous levels.
The Hoosier Health and Wellness Alliance (HHWA) seeks t o increase positive health outcomes within Indiana by providing the support and effective strategies needed to optimize local impact. HHWA values collaboration, education and food equity. Learn more here .
Select the membership level that you best identify with.
* must provide value
General Membership (Entry Level) - General Members receive general information and periodic information from the coalition via email or social media.
Partner Membership (Mid-Level) - Partner Members actively attend coalition meetings, participate in discussion around coalition activity and direction in addition to the previous level.
Active Membership (High Level) - Active Members participate in the coalition workgroups, which seek to engage in coalition activities that propel the current strategic direction that has been approved by the coalition in addition to the previous levels.
Please indicate your interest in working on issues related to the following areas. Select all that apply.
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Physical Activity
Nutrition
Food Insecurity
Food Access
Food Environments
Substance Misuse/Mental Health and how it relates to Nutrition/Physical Activity
Collaboration
Policy, Systems, and Environmental Change
K-12 School Health
Please indicate the types of skills that you have and are interested in contributing to HHWA. Select all that apply.
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Data Collection
Evaluation
Strategic Planning
Fundraising
Trainings
Media Outreach
Social Networking
Grassroots Organizing
Event Planning
Grant Writing
Presentations
Public Speaking
Meeting Facilitation
Writing and Editing
Other
Please describe other skills.
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The Indiana Joint Asthma Coalition (InJAC) is developing Indiana’s statewide strategic plan, collaborating with other agencies, health departments, and stakeholders in rural and urban communities to address and create long term sustainability of asthma programming. The coalition aims to increase asthma awareness and education, create asthma action plans, and decrease the prevalence of asthma in adults and children throughout the state. Learn more here .
Select the membership level that you best identify with.
* must provide value
General Membership (Entry Level) - General Members receive general information and periodic information from the coalition via email or social media.
Partner Membership (Mid-Level) - Partner Members actively attend coalition meetings, participate in discussion around coalition activity and direction in addition to the previous level.
Strategic Membership (High Level) - Strategic Members participate in the coalition workgroups, which seek to engage in coalition activities that propel the current strategic direction that has been approved by the coalition in addition to the previous levels.
Which sector(s) do you represent?
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Health Care Systems
Community-Based Organizations
Local Government
Military
Educational Systems
Statewide or National Organizations/Associations
Businesses
Community Member
Other
Please describe the 'Other' sector.
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Which healthcare system(s) do you represent?
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Community Health Centers
Hospitals
Community Health Workers
First Responders
Mental Health Providers
Pharmaceuticals
Health Insurance
Quality Assurance
IU Simon Comprehensive Cancer Center
Other
Please describe 'Other'.
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Which local government entity(s) do you represent?
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Local Health Department
Housing Authority
Government Officials
Parks and Recreation
Other
Please describe 'Other'.
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Which military entity(s) do you represent?
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Veterans Services
National Guard
Building Healthy Military Communities
Other
Please describe 'Other'.
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Which educational system(s) do you represent?
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Local School Corporations
Universities
Purdue Extension
Student
Other
Please describe 'Other'.
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Which statewide or national organization(s) do you represent?
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Indiana Department of Health
Indiana Family and Social Services Administration
Indiana Rural Health Association
Indiana Public Health Association
Indiana Minority Health Coalition
Indiana Cancer Consortium
Jump IN
Other
Please describe 'Other'.
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Which business entity(s) do you represent?
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Chamber of Commerce
Banking
Agriculture
Medical Supplies
Manufacturing
Local Small Business
Other
Please describe 'Other'.
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What is your health area(s) of work?
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Asthma
Cancer
Cardiovascular Disease
COVID-19
Diabetes
Health Care Access
Health Equity
HIV
Immunization
Infant and Maternal Health
Infant Mortality
LGBTQI Health
Mental Health
Minority Health
Nutrition
Obesity
Stroke
Substance Misuse
Tobacco/Vaping Cessation
Viral Hepatitis
Other
Please describe 'Other'.
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