Commitment Form

Thank you for your commitment to joining the AHA’s Age-Friendly Health Systems Action Community convening September 2021. Participation in the Action Community — including all webinars, coaching and resources — is free.

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

Organization Name

Organization Type

Address

City/Town

State/Province

Country

Is your organization an AHA member?

Organization AHA ID

Full Name

Job Title

Organization Website

List who would like to enroll in this Action Community.

Please enter the clinical sites, if inpatient or outpatient setting, and a key contact for each site.

Example: Test Hospital Unit 1 | inpatient | Jane Smith | jsmith@test.org

Site(s)

Site(s)
Site(s) Site Name Setting Key Contact Name Key Contact Email

Note: Add additional sites using the + option.

What type of electronic health system does your organization use?

Please identify your senior leader or sponsor. The senior leader/sponsor will support scale-up for your team and participate in the Leaders & Sponsors webinar track.

Senior Leader Name

Senior Leader Title

Senior Leader Email

Has your organization participated in a previous 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.

Team members:

Team members:
Team members: Full Name Email

Please note that you will need a clinical team to join the Action Community. If you are an agency, foundation, or other partner interested in joining the Age-Friendly Health Systems Action Community, please email ahaactioncommunity@aha.org to join our communications list.

Partners:

Age-Friendly Health Systems

AHA Center for Health Innovation

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Partners: