Join the Chiropractic Freedom Coalition

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Complete this form to be added to the Chiropractic Freedom Coalition!

First Name *

Last Name *

Email *

Cell Phone Number *

Address

City

State *

Zip

Are you a DC or Student *

Student

Other:

If you are a student, what school do you go to? *

Life Chiropractic College West

Life University

Sherman College of Chiropractic

Palmer College of Chiropractic - Davenport

Palmer College of Chiropractic - Florida

Cleveland University – Kansas City

Parker University

Logan University

Northeast College of Health Sciences

Southern California University of Health Sciences

Northwestern Health Sciences University

National University of Health Sciences

D’Youville College

Texas Chiropractic College

Keiser University

University of Bridgeport School of Chiropractic

University of Western States

Other:

Practice Name

Years in Practice

Are you a member of a State Board of Chiropractic Examiners? *

Yes

Are you a board member or active in your state association? *

Yes

Are you a key member of any other chiropractic groups or organizations? If so, what groups?

Additional comments:

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