*Name 

Are you representing your organization?  yes  no

Indicate where to send mail:  Business  Home

Name of Organization 

Title: 

*Address 

*State *Zip

*Phone:  Fax 

*Email Address: 

Does your organization have a newsletter?  yes  no

What particular interest, expertise or skills do you bring to the coalition?

Indicate a committee you would be willing to serve on:

Communication  Public Policy  Data  Education

Would you be willing to serve as a spokesperson ?  yes  no

Would you be willing to serve in a leadership position?  yes  no

Can you suggest other potential members (name & address) for the coalition?