Membership Commitment Form

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Membership Commitment to Support the T.E.A.M. Mission & Vision
Mission: To educate & advocate for healthy tobacco-free communities.
Vision: To reduce the negative impact of tobacco in our communities.

Email *

I as an individual and/or as a representative of the organization listed support the mission & vision of T.E.A.M.

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name *

Last Name *

Company Name *

Phone Number *

Email Address *

Address *

City *

State *

Zip *

Availability (please check all that apply) *

I am available to help during the day

I am available to help in the evening

I am available to help on weekends

I am available to help during the summer

Required

I am willing to: (please check all that apply) *

Help with events

Work on policy advocacy opportunities

Work on media advocacy opportunities.

Serve in a leadership position

Contact my elected officials

Translate materials or at an event

Contribute content to the website

Help with grant-writing

Other:

Required

Comments:

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This form was created inside of CHI Health Midlands. Report Abuse

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