Take Care New York Registration Form

Information and Resources
For Your Health

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Information for:

Health Department:

Take Care New York: A Policy for a Healthier New York City

Please complete the application below; a member of the Take Care New York staff will contact you to discuss next steps.

^*Date:
^*Organization Name:
^*Address 1:
Address 2:
^*City:
^*State:
^*Zip code:
^*Phone Number:
Fax number:
Website:
Type of Organization (Please check one): Community Based Organization/Non-Profit NYC Agency Hospital Other Health Care Provider Health Insurance Plan School Faith Based Organization Business Other (Please Specify):
^*CEO/Executive Director Name:
^*Title:
^*Phone Number:
Address if different than above:
City:
State:
Zip code:
Email Address:
Person in your organization who will serve as the Take Care New York Liaison:
Title:
Phone Number:
Email Address:
Address if different than above:
City:
State:
Zip code:
Please choose the Take Care New York priority area(s) that your organization is interested in working on: 1. Promote Quality Healthcare for All 2. Be Tobacco Free 3. Promote Physical Activity and Healthy Eating 4. Be Heart Healthy 5. Stop the Spread of HIV and other Sexually Transmitted Infections 6. Recognize and Treat Depression 7. Reduce Risky Alcohol Use and Drug Dependence 8. Prevent and Detect Cancer 9. Raise Healthy Children 10. Make all Neighborhoods Healthy Places
*^CEO/Executive Director Signature:** (Please note: the signature of the CEO or equivalent is required to become an official Take Care New York Partner) By checking this box, you agree and acknowledge that you are the CEO/Executive Director of your Organization or that you are authorized to represent the CEO/Executive Director of your Organization for the purpose of the Partnership application.

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