Membership Application Form
Please complete the following form for membership consideration in the LIFE Ambassadors of TEXAS. For required responses that are not applicable to your organization, submit the text "N/A".
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Name of Organization *
Physical Address *
Mailing Address *
Organization Main Phone Number *
Organization Client Website *
Organization Donor Website *
Organization Executive Director/ CEO *
Executive Director/ CEO email *
Executive Director/ CEO cell phone *
Chairman/President of Board of Directors *
Board Chair/President email *
Affiliations (check all that apply) *
Required
Medical Center/ Clinic *
Name of Medical Director *
Which medical services do you currently provide? (Check all that apply.) *
Required
How many hours per week is your primary location open to clients/patients? *
How many non-mobile satellite locations does the organization operate? *
How many mobile clinics does the organization operate? *
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