National Baptist Convention, USA, Inc. H.O.P.E. HHS Partnership

PO Box 994
Hernando, MS 38632

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H.O.P.E. Volunteer Commitment Form

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*First Name:

*Last Name:

*Email:

*Phone:

*Contact Preference:

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*Church Name:

Church Address

Church Web Site:

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Church State/Province:

Church ZIP/Postal Code:

*State Convention

*Area of Expertise:

Health Ministry Advocate Health Professional: MD, RN, etc. Dietician Community Health Worker Other (Include in the comments box below.)

*Area of Interest:

Alzheimer's Disease Association American Cancer Society Prostate Cancer Awareness Sickle Cell Anemia Disease Association Other (Include it in the comments box below.) American Diabetes Association American Heart Association American Kidney Fund American Stroke Association Breast Health Awareness HIV/AIDS Awareness Lupus/Multiple Sclerosis Pancreatic Cancer Awareness Network

*Does your church have an existing health ministry?

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*Are you interested in taking or hosting a H.O.P.E. Health Ambassador Training?

Yes (If yes, include possible dates in the comments box.) No

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PO Box 994
Hernando, MS 38632