Immunize Kansas Coalition | Interest Form

Engage with IKC

Thank you for your interest in IKC! We are excited to connect with you. Please fill in the form below and our staff team will follow-up with you, as needed.

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* 1. Name

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* 2. Organization

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* 3. Mailing Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* 4. Email Address

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* 5. Preferred Phone

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* 6. How would you like to engage with IKC?

Subscribe me to the IKC newsletter and action alert emails

Send me calendar invites for IKC meetings

Contact me with more information about IKC membership

I am interested in becoming an individual IKC member

I am interested in my organization becoming an institutional IKC member

Other (please specify)

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* 1. Name

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* 2. Organization

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* 3. Mailing Address

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* 4. Email Address

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* 5. Preferred Phone

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* 6. How would you like to engage with IKC?

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* 7. How did you hear about us?