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To qualify as a COPE Community Health and Wellness Volunteer, please read the eligibility criteria on our COPE Website and complete all the information requested in this form.

Contact Details of Appointed CCHW Champion

Contact Details of CCHW Appointed Ambassador?

What organizatin membership level are you applying for?

Training sessions and Zoom presentations by guest speakers will be recorded so that we can share them publicly.  You may appear in these recordings although we will edit out any Q&A that take place during these sessions.  Additionally, we may take photographs or video recordings at in-person gatherings for use in promotional materials. 


By checking the box below, you agree to participate in these recordings and give permission and agree to allow us to use your name and/or image in our materials.

Thank you! We’ll be in touch.

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