HSHP Board of Directors ApplicationBOD Application I subscribe to the purpose of the Hot Springs Health Program, Inc. as stated in its article of incorporation and request corporate membership. I am 18 years old or older and I am a resident of Madison County. I use/will use the services of the Corporation. By signing the below, I state I am not an active employee of Hot Springs Health Program or immediately related to any active employee of the Hot Springs Health Program. Name * Name First Name First Name Last Name Last Name Mailing Address * Email * Phone * The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in the program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/nation origin of individual applicants on the basis of visual observation or surname.Opt Out Option I do not wish to furnish this informationEthnicity Not Hispanic or Latino Hispanic or LatinoRace American Indian or Alaska Native Asian Black or African American Caucasian Native Hawaiian or Other Pacific Islander Hot Springs Health Program is an equal opportunity program. Discrimination is prohibited by Federal Law. Complaints of discrimination can be filed with the Secretary of Agriculture, Washington, DC 20250 Mission Hot Springs Health Program is dedicated to serving the primary health care needs of the people of Madison County and surrounding areas through an organization oriented to and directed by the community. Submit If you are human, leave this field blank.
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