Healthy Androscoggin - Membership Application

Get Involved Form

Membership Application

Your Name:
Mailing Address:
City/Town:
State:
Zip:
Employer:
Job Title:
Home Phone:
Work Phone:
Fax #:
E-Mail:

Best Time/Method to reach you:

In what capacity would you volunteer your services? (Check any that are of interest to you)
Media/Public Relations	Substance Abuse Prevention amoung Youth
Worksite Wellness	Youth/Schools
Tobacco	Physical Activity
Speaker Bureau	Special Projects
Keeping Informed

Other:

Membership Agreement
I certify that the above information is correct. I hereby agree to remain committed to the mission and goals of the Healthy Androscoggin Coalition.
Yes I agree	No I do not agree