If you would like more information
of the Elkhart County Minority Health Coalition and the
programs and services we offer, please contact: Minority Health Coalition of Elkhart
County, Inc. Post Office Box 218 Elkhart, IN 46515-0218 574.522.0128 574.293.1403 Fax Membership Application
Please join the Minority Health Coalition of Elkhart County TODAY, and receive current information regarding minority health issues. Contributions are tax deductible.
Return this form with your check payable to:
Minority Health Coalition, Inc.
Elkhart County
PO Box 218
Elkhart, IN 46515-0218
Name: ______________________________
Title: _______________________________
Organization: ________________________
Address: ____________________________
City: ____________ST: _____ Zip: _______
Telephone Number: ___________________
Fax Number: _________________________
Annual Membership Fee Please Indicate:
( ) Individual Membership ($10)
( ) Organizational Membership ($20)
( ) Affiliate (seniors/students) ($5)
( ) Corporate Membership
( ) Bronze - $100
( ) Silver - $250
( ) Gold - $500
( ) Platinum - $1,000
*Bronze, Silver, and Gold Corporate Membership with receipt certificates, Platinum members will receive a plaque.