First name:
Last name:
Title
Supervisor name:
Name of organization
Mailing address:
City:
State:
Zip code:
Business phone:
Fax:
Cell phone:
Email address:
Website:
Name of alternative representative:
Phone of alternative representative:
Brief description of your organization:
Personal interest/goal for joining:
Special skills or talents:
Current/Past community involvement in children's health issues:
Of our existing sub-committee areas, I prefer to serve on: Community awareness
Legislative advocacy
May we list your organization as a member in our printed materials, literature and website? Yes
No