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AUCH Annual Membership Renewal Application

Being a member of The Association for Utah Community Health (AUCH) demonstrates your commitment to an equitable health care system that provides access to quality services for all Utah residents. AUCH is a membership organization comprised of non-profit, community-based primary healthcare providers. AUCH is the federally recognized Primary Care Association for the State of Utah. Membership is available to those maintaining a health care program with an expressed purpose and primary function of providing comprehensive primary care services to low-income, medically underserved individuals in Utah. Each organizational member shall be entitled to appoint one individual with voting privilege to the AUCH Board of Directors. AUCH actively represents the interests of its membership through strong, inclusive advocacy, and provides trainings, technical assistance, and specialized resources for its members.

Your Name(Required)

Organization Information

Organization Address

Statement of Collaboration

On behalf of, and with full consent of the Board of Directors of
I understand and agree, as a term of membership in the Association for Utah Community Health, that the organization stated above will at all times operate in a manner which is consistent with AUCH’s mission, goals, objectives, and implementing policies.

Statement of Commitment

Agrees to the following, by checking each box:(Required)

Conflict of Interest Policy and Annual Statement

Click here to read the Conflict of Interest Policy and fill out AUCH Director and Officer Annual Conflict of Interest Statement.
Are you a voting member of AUCH's Board of Directors?(Required)
Are you an Officer on AUCH's Executive Committee?(Required)
I affirm the following (Please Initial):
Disclosures:
Do you have a financial interest (current or potential), including a compensation arrangement, as defined in the Conflict of Interest policy with AUCH?(Required)
Has the financial interest been disclosed, as provided in the Conflict of Interest policy?(Required)
In the past, have you had a financial interest, including a compensation arrangement, as defined in the Conflict of Interest policy with AUCH?(Required)
Was the financial interest disclosed, as provided in the Conflict of Interest policy?(Required)
Are you an independent director, as defined in the Conflict of Interest policy?(Required)

Signature

By entering your name here as your signature, you agree to the terms stated in the Statement of Collaboration, the Statement of Commitment, and Annual Conflict of Interest Policy & Statement.
MM slash DD slash YYYY

Required Documentation (Upload Files)

*As a condition of membership, please submit the following documentation:
Max. file size: 2 MB.
NOGA & Project Abstract
Max. file size: 2 MB.
MUST INCLUDE: Member Contact List, Election and Board Meeting Dates
Max. file size: 2 MB.
Please update the form that was sent out via email and upload it here
*The AUCH Board of Directors require that all members annually submit the above-mentioned documents.

Once you submit your application, you will receive an email from AUCH with your 2024/25 Annual Membership dues invoice. If you have any questions, please contact Beth Fiorello at beth@auch.org.
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AUCH | Association For Utah Community Health logo

© 2025 Association for Utah Community Health

860 East 4500 South, Suite 206, Salt Lake City, Utah 84107
(801) 974-5522
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