Thank you for your interest in CivicWell membership!

Once you complete your application you will be directed to your payment options. You may either

pay online or request to be invoiced. If you have questions or problems with this form, contact

members@civicwell.org

Primary Contact

First Name *

Last Name *

Title *

Organization/Affiliation *

County *

Region *

Population *

Phone *

Email *

Mailing Address *

Suite, Unit, Apt,

City *

State *

Zip *

Website / Social Media

Alternate Contact (optional)

First

Last

Phone

Email

Membership Options

Membership status *

I am a new member

I am a renewing my membership

Membership Level *

Agency - Cities, counties, special districts, and state agencies—annual fee depends on population served. Entitles 10 people to membership benefits. Once you select "Agency" as your Membership Level, you will be able to enter the contact information for the people below.

Change Maker - Individual local elected officials, government staff, CBO staff, community leaders, and supporters. Includes an acknowledgment on our social media.

Leader - Individual local elected officials, government staff, community leaders, and supporters.

Student - Students, CivicSpark Fellows, and CivicSpark alumni.

If you have a discount code, please enter it below.

Agency Member Contact Information

Please enter the contact information for the up to 10 members you would like to have under your Agency membership.

1. Name ( First & Last)

Title

Phone Number

Email Address

2. Name ( First & Last)

Title

Phone Number

Email Address

3. Name ( First & Last)

Title

Phone Number

Email Address

4. Name ( First & Last)

Title

Phone Number

Email Address

5. Name ( First & Last)

Title

Phone Number

Email Address

6. Name ( First & Last)

Title

Phone Number

Email Address

7. Name ( First & Last)

Title

Phone Number

Email Address

8. Name ( First & Last)

Title

Phone Number

Email Address

9. Name ( First & Last)

Title

Phone Number

Email Address

10. Name ( First & Last)

Title

Phone Number

Email Address

Focus Areas

What are your focus areas? (Check all that apply) *

Assistance

What would you like assistance with as a member of CivicWell? (Check all that apply)

Meeting and networking with other local leaders

Partnership/mentorship from another local leader on a specific topic

Information on grants and free technical assistance for local planning projects

A biweekly newsletter featuring available funding opportunities

Assistance in crafting and adopting specific policies

Assistance in designing a larger Healthy Communities agenda for my community

Implementation assistance for a new program or policy

Nothing at this time

Community Vision and Smart Growth Successes

In an effort to better meet the needs of our members we would like to gather some information regarding our members' vision for a great community and smart growth successes.

In a few words, describe your vision for a great community. For example, you might discuss what a healthy, livable community means to you; how smart growth and strategies could strengthen your community; or simply why you are interested in smart growth. (optional)

Please share any recent smart growth successes in your community (e.g., downtown revitalization, bicycle and pedestrian improvements, mixed-use development project, a new farmers' market, etc).

The CivicWell national network is made up of policymakers and emerging leaders. Together, our members pursue innovative smart-growth and climate resilience strategies, seek new partners and tools to build thriving communities, strengthen local economies, and enrich the lives of all residents.

With the help of our network of visionary local elected officials and community leaders, we work to transform communities by inspiring each other and sharing promising strategies for resilient and equitable communities. As a CivicWell member, you will have access to our direct assistance and practical tools for implementing on-the-ground successes in your community.

*

Yes, I endorse the CivicWell Membership pledge.