Membership Profile & Application: 

Regional coalitions strive to improve the health and quality of life within their communities by implementing policy, systems and environmental changes. Become a part of the movement for a healthier Louisiana by contacting your regional coalition or completing a membership application. A healthy community starts with you!

To join a Regional Coalition, simply fill out and submit the contact form below. 

Date *
Date
Name *
Name
First name / Middle initial / Last name
e.g. MD, MPH, MBA, etc.
Mailing Address *
Mailing Address
Phone *
Phone
Cell Phone
Cell Phone
AD-HOC COMMITTEES
check all that apply
Community Representation
check all that apply
Please check the category that most accurately describes your involvement in the coalition: *