To join the DC Tobacco Free Coalition, complete and submit this member application.

 

Membership Agreement

Vision: The vision of the Coalition shall be to have 100% smokefree environments for all District residents & to improve the quality of life for all by reducing health risks related to tobacco use and exposure.

Mission: The mission of the Coalition shall be to improve the health of the District of Columbia residents by decreasing the morbidity and mortality associated with tobacco use and exposure through education, public policy, and advocacy using culturally and linguistically competent approaches.

Conflict of Interest: I affirm that, as of today, I/we have not accepted tobacco industry funds in the past year.

Type of Membership *
**Voting rights: one vote per organization
Name *
Name
Address
Address
Phone
Phone
Committee(s) Selection
Please indicate the committee on which you would like to serve:
Communities Served
Primary Population Served: (check all that apply)
Areas of Interest
Please indicate any additional area(s) of interest: this will aid us in collaboration, growth, and retention efforts.