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MEMBERSHIP REGISTRATION

Be part of something great! Join the Breast Health Collaborative of Texas. By providing the information requested below, you will be listed as a member of the Collaborative. Those joining as organizations also consent to the organization’s information being listed on the Breast Health Portal (www.BreastHealthTexas.org), an online resource of breast health providers and data.

• Membership is immediate
• Voting privileges are granted to all members
• Meetings are bimonthly
• No membership dues

I am joining as: An individual An organization/clinic

Name: Job Title:

Organization/Clinic:

Contact information: Personal (Individuals only) Work/Business address

Street Address: City, State, Zip:

Phone: Fax:

Email address:

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If joining as an organization, fill out the following information. If joining as an individual, skip to the submit button at the end.
If your organization is nonprofit and offers breast health services, you are consenting to being included on the Breast Health Portal (www.BreastHealthPortal). It is free to be listed and free to use.

Appointment Phone (if applicable): Counties Served:

Website:

Brief description of the mission or services provided:

Organization Type (select one) City Clinic County Clinic FQHC or FQHC look-alike Hospital District Nonprofit Hospital Nonprofit Agency n/a (individual)

Types of Services - Select all that apply:

Education Support Resources Screening Diagnosis Treatment

Yes, you have my permission to link from the Collaborative’s website to my website.

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For more information on Membership, contact Lyn Widlaski at lwidlaski@therose.org ● 281.464.5334
For more information on the Breast Health Portal, contact Lyn Widlaski at lwidlaski@therose.org ● 281.464.5334 OR Jeanne Hanks at jhanks@sleh.com ● 832.355.4460

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