Your Voice Your Value Pledge Sign Up
I/my organization would like to join the Your Voice, Your Value coalition and be listed as a member. I am/our organization is committed to protect the disability community and those fighting chronic diseases from the discriminatory practice of value assessments. I look forward to being contacted about opportunities to advocate against the use of value assessments in determining access to medicines.
Please select a membership category: *
Name: First & Last and or Organization Name *
Address (Street) *
City *
State *
Zip *
Phone *
Email *
By Typing my name/ or organization name below and submitting this form is my - My electronic signature *
Never submit passwords through Google Forms.
This form was created inside of Familia Unida. Report Abuse