Individual Signup Form

New York Coalition for Healthy School Lunches
Membership Application Form – for Professionals (food service, education, or health)

By signing this form, you agree to officially endorse the goals of the organization in accordance with our mission statement; Be listed as a Coalition Member on the Coalition's website, Coalition materials, and other places where appropriate; Retain independent identity but agree to support the organization in the achievement of mutual goals.

Name:
Street or Post Office Box:
City:
State:
Zipcode:
Telephone Numbers - Please include area codes
Home Phone:
Work Phone:
Cell Phone:

Email Address:
School District that you reside or work in:

Please select your profession:
If "Other," please enter profession:

May we have your permission to list your name, profession, and city/school district on our website?	Yes No

Are you interested in volunteering?	Yes No
If you are interested in volunteering, how?