Membership Form
You can become a member online at
www.kyoralhealthcoalition.org or fill out the following
form and mail it with your check to:
Kentucky Oral Health Coalition
11001 Bluegrass Pkwy., Ste. 100
Jeffersontown, KY 40299
Make checks payable to:
Kentucky Oral Health Coalition
Please select the appropriate membership category:
B STUDENT – Annual dues of $10
B INDIVIDUAL – Annual dues of $50
B G
OVERNMENT/QUASI-GOVERNMENTAL
ORGANIZATION – Annual dues of $150
B NON-PROFIT ORGANIZATION – Annual dues of $300
B FOR-PROFIT ORGANIZATION – Annual dues of $500
Member Information:
Name
Today’s Date
Organization
Phone #
Email
City
StateZip
County of residence (for individual/student members only)
School/Degree(for student members only)
11001 Bluegrass Pkwy., Ste. 100
Jeffersontown, KY 40299
Address
Kentucky Oral Health Coalition
(KOHC) is a group of concerned
citizens, advocates, and
professionals working together to
improve oral health across Kentucky.
Guiding Principles
Vision Statement: All people of Kentucky
can enjoy optimal oral health for life
Become a Member of KOHC
Contact KOHC
• Work collaboratively to make a true impact on oral
health in Kentucky.
www.kyoralhealthcoalition.org/contact-us
• Network with others at coalition meetings and events.
• Vote on coalition decisions including policy
priorities, election of officers, and other coalition
related decisions.
• Attend coalition meetings and activities and take
part in coalition workgroups.
Mission Statement: Improve the oral
health of all people of Kentucky
• Receive CEU credits by attending coalition’s annual
meeting.
Goal Statements
• Marketing opportunities for organizational
members. Logos will appear on various publications,
promotional materials and related documents as an
organizational member of the coalition.
1. To advocate for improved access to oral
and general health prevention, services,
and education for all people of Kentucky
by 2020
2. To promote and encourage active
interaction, effective collaboration and
cooperation between all providers of oral
and general health care and individuals
and population within Kentucky needing
oral health services, prevention, and
education through the establishment of
public-private partnerships by 2014
3. To actively participate, communicate,
and encourage relationships of the
Kentucky Oral Health Coalition with
other advocacy groups in promoting
oral and overall health for all people of
Kentucky beginning in 2012
Current Officers
Chair
Dr. Nikki Stone
Chair Elect
Dr. Stephanie Roney
Treasurer
Deborah Wade
Secretary
Ada Carlile
Immediate Past Chair
Dr. Laura Hancock Jones
Types of Membership
• Student Individual Member (Voting Member) –
Annual dues of $10 (must be a full-time student)
• Individual Member (Voting Member) – Annual
dues of $50
• Government/Quasi-governmental Organization
(Voting Member) – Annual dues of $150
• Non-Profit Organization (Voting Member) –
Annual dues of $300
• For-Profit Organization (Voting Member) –
Annual dues of $500
Memberships are good for one year. Dues are renewed
annually in July. Your dues provide resources to support
annual coalition meetings, oral health coalition activities as
approved by members or the executive committee, and
policies and programs to increase access to high quality
oral health care for all populations in Kentucky.
11001 Bluegrass Pkwy., Suite 100
Louisville, Kentucky 40299
502-895-8167
Oral Health Facts
• Kentucky has the fifth highest rate of
“toothlessness” in the country among adults
65 and older.
• A 2012 national study by the Pew Center
on the States gave Kentucky a grade of D
for its ability to provide dental sealants to
children.
• Only 60 percent of Kentucky adults reported
visiting a dentist or dental clinic in the
previous 12 months in 2012.
• The 2012 Kentucky Health Issues Poll
(KHIP) found 1.7 million Kentucky adults
lack dental insurance.
Stay up to date on news
and events of KOHC at
www.kyoralhealthcoalition.org.