MOLAR Maricopa Country Oral Health Leaders Advocates and Resources

Online Member Application

1. Name:(*)
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2. Organization/Affiliation:(*)
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3. Role:
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4. Address:(*)
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5. City:(*)
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6. State:(*)
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7. Zip code:(*)
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8. Phone:(*)
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9. Fax:
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10. E-Mail:(*)
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11. 
    
    

    Membership Type (please check only one type)
12. Charter Membership (select from the following):
    
    Individual ($25)
    Organization (Up to 5/$75)
    Corporation ($500)
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13. 
    

    • Participate in Coalition meetings and activities;
    • Receive mailings and notices;
    • Eligible to vote;
    Eligible to hold elected office within the Coalition;
    • Note that as an Active member you need to participate in at least one of the following Standing Committees or Work Groups.
    

    
    
14. Please check which one(s) you are interested in serving on:(*)
    Access to Care & Advocacy (standing committee)
    Children (work group)
    Communication & Marketing (standing committee)
    Developmental Disabilities (work group)
    Education, Awareness, & Prevention (standing committee)
    Integration of Dental & Medical (work group)
    Low Income Adults (work group)
    Older Adults (work group)
    Resource Development (standing committee)
    As an active member you need to participate in at least one Standing Committee or Work Group. Please choose one.
15. 
    Student Membership:
    
    Individual (Free for those in Maricopa County)Invalid Input
16. 
    

    • Receive mailings and notices;
    • Encouraged to attend general membership meetings;
    • Welcome to speak on an issue at meetings;
    

    
    
17. Personal Statement (please briefly describe why you would like to join MOLAR):(*)
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18. 
    How did you find out about MOLAR?
    WebsiteColleagueFacebookNewsletterE-mailOtherInvalid Input
19.  

1. Help us get to know your organization better.
2. Website:
3. Mission/Purpose (What do you do? Who is your target audience? Why do you do it?):(*)
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4. Type of Organization (Check all that apply)
   Association
   Clinic
   Foundation
   Government Agency
   Nonprofit
   Private Practice
   Other
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5. Feel free to provide brochures, annual reports, or other materials that may be helpful.
6.  

1. Please read the Conflict of Interest and Legal Liability Policy and Statement of Commitment. Sign and submit with completed application.
2. Statement of Commitment

   Our Mission:
   MOLAR advocates, educates, and communicates for greater access to oral health care for everyone in Maricopa County.

   Our Vision:
   MOLAR believes that everyone in Maricopa County should have accessible, affordable oral health care.

   Our Values:

   1. Oral health is an essential part of total health.
   2. No one should suffer from preventable, treatable oral disease.
   3. MOLAR values partnerships as a means to impact health care system changes.

   MOLAR members agree to:
   • Serve as an Ambassador for MOLAR in support of the Mission, Vision, & Values;
   • Share responsibility and accountability of outcomes;
   • Set realistic and measurable outcomes supported by MOLAR;
   • Monitor MOLAR’s progress and establish evaluation tools;
   • Affirm the Statement of Commitment.
3. Pledge(*)
   I affirm the above-mentioned principles to fulfill MOLAR's goals and to systematically and actively monitor the progress we make in doing so. I further pledge to report regularly on this progress.Invalid Input
4. Your Digital Signature(*)
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   Enter your name in this field to serve as the acknowledgement of the pledge above.
5.  

1. Conflict of Interest and Legal Liability Policy from the MOLAR Rules of Operation
2. 1. MOLAR members shall not be financially interested in any action made by MOLAR or any action they take in their capacity as MOLAR members.
   2. A MOLAR member, who maintains a direct or indirect financial interest in any action considered by MOLAR, shall disclose the interest during MOLAR meetings and have the disclosure specifically noted in the minutes of that meeting. The affected MOLAR member shall not vote or debate the matter in conflict or attempt to influence any other MOLAR member on the subject in question.
   3. MOLAR members shall not accept compensation, gifts, favors or other benefits from an individual, firm or organization for work performed as a MOLAR member.
   4. MOLAR shall not endorse any person, company, product or procedure without the specific approval of the Executive Council. Any contributions from corporations or foundations will be disclosed by MOLAR to its members and the public.
   5. MOLAR members shall not use their official capacity in MOLAR to solicit or otherwise influence others for personal reasons or benefits.
3. Agreement(*)
   I have read and agree to the MOLAR Conflict of Interest and Legal Liability Policy. By signing below, I pledge to become a member of MOLAR.Invalid Input
4. Your Digital Signature(*)
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   Enter your name in this field to serve as the acknowledgement of the agreement above.