Our Healthy Futures

Free Trial User Agreement

Acknowledgment & Profile Form

Instructions: We are pleased that you have an interest in the Community Health Impact Connection Website. Before you receive a log in, and password, please read and complete the following form. Your log in, and password will be sent to your email.

Organization Profile

Organization Name

Street Address

City, State, and Zip

Primary Contact Information

Name

Telephone

Title

Fax:

Service Acknowledgment

You certify that you are authorized to execute this written acknowledgment and to access the CHiC Website on behalf of (Name of Organization)

You understand and acknowledge that your organization will have access to the CHiC website for 30 days. At the end of this trial period, Florida Hospital will have no further obligation to provide your organization access to the CHiC website.

I understand and acknowledge

Such access WILL TERMINATE, UNLESS your organization has executed a License Agreement with Florida Hospital that authorizes your organization to continue to use and access the CHiC Website

I understand and acknowledge

Name

Title

Organization

Address

City, State, and Zip

By cecking this box you are providing written acknowledgement to this form.

I understand and acknowledge

Date

Our Healthy Futures

Contact Details

Free Trial User Agreement

Instructions: We are pleased that you have an interest in the Community Health Impact Connection Website. Before you receive a log in, and password, please read and complete the following form. Your log in, and password will be sent to your email.

Organization Profile

Primary Contact Information

Service Acknowledgment