Join Our Campaign

1. Sign On to HCFANY

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* 1. Please indicate if you are acting as an:

Individual or Small business (not affiliated with an organization)

Organization

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* 2. Please choose ONE:

Yes! We endorse HCFANY's 10 Standards for Quality, Affordable Health Care for All. Please sign me or my organization (as indicated above) up to be a HCFANY a campaign member (open to all organizations who serve, represent, or advocate for consumers)

NO - I or my organization cannot join HCFANY right now, but please sign me up for your email list so that I can be kept informed of campaign activities.

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* 3. For individuals/organizations that are signing on, please fill in all fields. If you only wish to sign on to HCFANY's mailing list, you only need to fill in your email address.

Name: *

Company:

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address: *

Phone Number:

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* 4. Please indicate the scope of your organization

Statewide

Regional

Local

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* 5. Please indicate if your organization is

a Coalition

a trade/professional group

other