Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.

COMMITMENT AND INTEREST FORM

Name:    Title: Agency: Address:

Phone:    Fax:    Email:

I am definitely interested in participating in Healthy Volusia! Sign me up right away to participate on the following Healthy Volusia team:   Diabetes Team   Heart Disease & Stroke Team   Infant Mortality/Low Birth Weight Team   Mental Health & Suicide Team   Nutrition & Overweight Team   Physical Activity & Fitness Team   Sexually Transmitted Diseases/HIV Team   Tobacco Team       I am interested in supporting the Healthy Volusia Partnership by committing the following:   staff in-kind time   printing meeting materials   hosting meetings at my agency   refreshments for meetings   refreshments for community activities   assisting with focus groups, interviews, etc.   other, please specify in comments section     I am not interested in participating on Healthy Volusia assessment teams, but am interested in attending the full partnership meetings.     I wish only to be placed on the mailing list.     COMMENTS:

Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.
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