Florida Flu & Pneumonia Coalition Registration Form

As a member, or member agency, I aggree to support the mission of the Coalition. I will receive regular informational updates, membership materials, or other privileges. I will be expected to attend a minimum of 4 of 12 teleconferences per calendar year. I will be entitled to one vote on matters of concern before the Coalition, and may list my organization on the Colalition web site.
Indicates a required field *
	First Name	*
	Last Name	*
	Organization Name
	Address	*
	City	*
	State	*
	Zip	*
	Phone	*
	Fax
	EMail	*
	Organizations Web site
	Membership Type
	Please state reason for membership (Check all that apply)
	Networking Sharing outlet
	Information
	Educational Resource
	Other
	If Other please explain
Once registration form is submitted you will receive an email with login/password information for immediate access to the Coalition Members-only page of the Florida Flu & Pneumonia Coalition web site. Any additional Coalition materials will be sent through the US mail.