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Take Heart Alaska Coalition Membership
Join the Take Heart Alaska Coalition
Please complete the following form to express your interest in joining the coalition.
*
Name:
(Required.)
First Name:
Last Name:
*
Contact Information:
(Required.)
Address:
City:
Zipcode:
Email Address:
Phone:
Fax:
Work-related Information:
Organization:
Program:
Title:
For information on the committees and subcommittees goals and projects, go to the
Take Heart Alaska website
.
Take Heart Alaska Committees:
Healthy Lifestyles
Public Education
Professional Education (for practitioners)
Treatment and Secondary Prevention Subcommittees:
Cardiac Systems of Care (for practitioners)
Stroke Systems of Care (for practitioners)
Tell us a little about your background and how you plan to contribute to the coalition:
*
Can we publish your name as a member of the Take Heart Alaska Coalition on the website?
(Required.)
Yes, you can publish my name.
Yes, you can publish my name and contact information.
No, please do not publish my information.
How did you hear about Take Heart Alaska?
Online
University
Department Memo
Printed Publications
From DHSS Staff
Press Release
Other (please specify)
