Lighten Up NH! Alliance Member Application

The goal of the Lighten Up NH! Alliance is to establish of a statewide collaborative to bring together agencies, organizations, concerned individuals and other stakeholders to address the problem of obesity in New Hampshire using research based information and best practices. For more information about the Alliance and the benefits of membership, please see the Alliance section of our website. If you have questions please contact our Educational Program Coordinator

1) Is this a new membership?
Yes
No

2) How did you hear about Lighten Up NH!
     Colleague
      Current Alliance member
      Professional organization
      Other

Contact Information

3) Please enter your name

4) Please enter your job title

5) Please enter your organization or affiliation

6) Street address

7) City

8) State

9) Zip Code

10) E-mail address

11) Telephone (including area code)

12) FAX number

13) What services does your organization provide to NH residents?

14) Is your organization
     Not-for-profit
      For Profit
      Governmental organization

15) Please provide any additional comments or information including any specific areas of interest/expertise, and contact information for other potential Alliance members.