CAN Team: Faith Community Representatives Form

I see my church body contributing by (check all that apply)

Recruiting volunteers from our church to assist clients through the process of getting the care they need.

Recruiting health care professionals from our church to volunteer time at the clinic providing treatment to clients.

Contributing donated funds to the operation of the clinic.

Promoting the clinic and referring those with needs to the clinic for their medical care.

Please list services/programs provided by your church body to those in need (e.g. food pantry, soup kitchen, clothing distribution, etc.)

Concerns I have regarding the clinic are

Opportunities I see regarding the clinic are

We support Buffalo County Community Partners effort to ensure that everyone in the area is able to access basic health care.

We would like to be listed as a partner of this effort. By checking this box you will be listed as a member of the Community Access Network (CAN) Team and receive communication regarding our communities progress.

At this time we are uncertain if we will be listed as a partner, but we would like additional information to be presented to our church governing body to learn how we can become a partner.

Name

First

Last

Last

Church

Email Address

Phone Number