Partnership Council - Contact Information Form

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Instructions: Please complete this form if you are either...

1. a CURRENT industry/higher education/community organization representative
2. a RETIRED industry/higher education/community organization representative

3. a RETIRED/FORMER health science educator and/or HOSA Advisor

This will allow you to be active on the Wisconsin HOSA Partnership Council contact distribution list. Joining this list provides you with more information about statewide programs, opportunities, and involvement based on the information you provide within this form! Any questions or concerns can be directed to contactus@wihosa.org.

First and Last Name *

Name of Employer/Organization (or indicate retired) *

Title (if retired, indicate background/former position) *

Email *

Phone Number *

Partnership Council Acknowledgement *

I agree to have the information provided above be added to the Wisconsin HOSA Partnership Council Contact List.

Professional Membership Affiliation Statement

Partnership Council Members are invited to become professional members of Wisconsin HOSA and HOSA - Future Health Professionals. Membership is encouraged but optional. Please email contactus@wihosa.org if you have any questions/concerns regarding Professional Division Membership.

The Professional Division of HOSA shall be composed of persons who have been enrolled in health science programs or persons who are associated with or participating in health science education in professional capacities. These may include health professionals, alumni or other adult members of the community who wish to assist and support the HOSA program and its growth and development. Professional Division members shall pay affiliation fees but may not vote, make motions, hold office or compete in events.

Professional Membership Affiliation *

I wish to become an affiliated Professional Member of HOSA, and will personally make the $17 contribution for annual affiliation dues

I wish to become an affiliated Professional Member of HOSA, please invoice my employer for my $17 annual affiliation dues

No, I do not wish to become an affiliated Professional Member of HOSA at this time.

HOSA Opportunities & Involvement

Please select all opportunities you would like additional information about or have interest in participating in... *

Wisconsin HOSA Board of Directors

Career Mentoring / Local Chapter Career Speaking Events

Competitive Events Judge - Regionals (Virtually in January)

Competitive Events Judge - State (In-person in April)

Exhibitor

Presenter/Speaker

Providing Job Shadows, Internships or Mentoring for HOSA Members

Scholarship Program (i.e, serve on review committee, provide a scholarship)

Sponsorship Program (i.e, support statewide programs, conferences/events, membership materials)

Serve in a volunteer or independent contracted role (i.e. state officer coach, conference coordinator support, marketing support, competitive events team, etc.)

Other:

Required

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