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If you are interested in joining the Maryland Healthy Eating and Active Lifestyle Coalition, please complete the form below. Once you have finished, click the Submit button and your information will be emailed to our Steering Committee.

If your organization is interested in signing up as a coalition partner, please complete the Partnership Form for Organizations [Word Document].

Name:
Title:  

Contact Information (Home):
Address:
City:     
State:           Zip:
Phone:  
Fax:     
E-mail:  


Contact Information (Work):
Address:
City:     
State:           Zip:
Phone:  
Fax:     
E-mail:  

Preferred place to be contacted:   Work  Phone