Membership Application

Texas Breastfeeding Coalition Membership Application

Please copy this information into an email and send to txbfcoalition@yahoo.com or mail along with your membership dues.

Membership type: ___ Individual ___ Organization

Annual dues: ___$10 individual ___$25 non-profits ___ $50 business
Make check payable to the Texas Breastfeeding Coalition and mail to: 6724 Oasis Dr., Austin, TX 78749

Name:

Address:

Email Address:

Phone number:

Fax number:

Organization/Affiliation:

Why do you want to be a member of the Texas Breastfeeding Coalition?

In which of the following areas do you have experience/expertise. Please describe briefly.

___ Legislation (My expertise is:

___ Media/PR (My expertise is:

___ Website development (My expertise is:

___ Medical school training/ CME (My expertise is:

___ Nursing school training / CNE (My expertise is:

___ Other professional training (My expertise is:

___ Businesses (My expertise is:

___ Texas legislature (My expertise is:

___ City / county government (My expertise is:

___ Hospitals (My expertise is:

___ Clinics (My expertise is:

___ Faith based organizations (My expertise is:

___ Schools K – 12 (My expertise is:

___ Colleges (My expertise is:

___ Community based organizations (My expertise is:

___ World Breastfeeding Week celebrations (My expertise is:

___ Quintessence Challenge (My expertise is:

___ Promoting local programs (My expertise is:

___ Other: ___________________________________________________________


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