Organization Sign-Up Form

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If your organization would like to sign the petition and join the Children's Health Care Campaign coalition please fill out and submit the form below. Someone will get in touch with you to confirm your submission and provide you with further information. (The contact information you provide is confidential.)

 

Organization Name:
Organization Web Site:
Contact First Name:
Contact Last Name:
Contact Title:
Phone Number:
E-mail:
Street Address:
City:
State:
Zip Code:
Are you authorized to sign the letter on your organization's behalf?	Yes  No