Request to Join | Membership Application

  • Mission Statement:
    To bring together health systems, hospitals, medical, dental and behavioral health providers, pharmacists, and health-care professional associations and supporting organizations to address the opioid/heroin crisis through awareness, education and action.

  • Instructions:
    This form is intended for individuals representing an organization interested in joining the South Central PA Opioid Awareness Coalition. Upon completing the fields below, the information will be sent for review to the appropriate county representatives.

  • Contact Information

  • (Choose at least one)
  • By signing and submitting below, I agree to:
    • Attend all schedule meetings
    • Abide by mission statement and the messaging contained within our fact sheet
    • Commit to work towards all goals defined by the South Central PA Opioid Awareness Coalition
    • Provide constructive and proactive input
    • Provide organization logos if applicable
    • Be inclusive by respecting different priorities and concerns
    • Perform tasks as determined during and outside of meetings
  • I agree to serve as a member of the South Central PA Opioid Awareness Coalition and promote the collective mission and disseminate communication materials. Please enter your full name to act as a digital signature for this application.
  • This field is for validation purposes and should be left unchanged.