Commitment Form for Age-Friendly

Thank you for your commitment to joining the AHA’s Age-Friendly Health Systems Action Community convening fall 2024. Participation in the Action Community — including all webinars, coaching and resources — is free.

Please complete this form and reach out to ahaactioncommunity@aha.org with any questions. We look forward to working with you!

View “Invitation to Join” Guide.

The Action Community curriculum is designed for clinical teams. If you are an agency, foundation or other partner interested in joining the Age-Friendly Health Systems Action Community, please email ahaactioncommunity@aha.org.

All teams joining the AHA Action Community after mid-October 2024 will be scheduled to receive a 1:1 onboarding call.

Contact Name

First Name

Last Name

Job Title

Are you the key contact for your care setting?

Who is your key contact?

Key Contact Name

Key Contact Email

Key Contact Job Title

Health System Name

Care Setting Name

Note:

Please identify your site of care if part of a larger hospital network, nursing home organization, etc.
If not applicable, please indicate NA.

To register additional care settings or units/teams within your organization, please submit a new form for each one.

Health System Type

Care Setting Type

Note: Specific to enrollment for this action community

Address

City/Town

State/Province

Country

Is your organization an AHA member?

Member ID

What type of electronic health record system does your organization use?

Has your organization participated in a previous Action Community?

Has your care setting been recognized by IHI as an Age-Friendly Health System Participant or Committed to Care Excellence?

Name of the care setting recognized.

If your setting has not been recognized, do you intend to pursue recognition as an Age-Friendly Health System Participant during this Action Community?

How did you hear about this Action Community?

Please list the emails of team members who would like to be added to the Action Community Listserv.

Please list the emails of team members who would like to be added to the Action Community Listserv.
Please list the emails of team members who would like to be added to the Action Community Listserv. Full Name Email

Note:

If you receive the message “Please select an item in the list” or “Please fill out this field,” scroll up to the respective location(s) and add your information.
After clicking “Join the Action Community," you will receive an onscreen message upon successful submission.

Partners:

Age-Friendly Health Systems

AHA Center for Health Innovation

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Who is your key contact?

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Partners: