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If you would like to become a member of the Kingston Health Coalition, please fill out the form below. Your name and telephone number are required so that we can contact you if needed, and please check the appropriate box or boxes regarding how you would like to get involved (member, donate, volunteer). Please leave any additional comments you would like to make in the comments box, and remember to click SUBMIT when you're done. Your response will be emailed directly to one of the Chairs. Thank you for your support!

 

Name:

Street Address:

City:

Province:

Postal Code:

Phone Number:
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Fax:
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E-mail:

 

Become a Member / Donate / Volunteer:

I would like to become a member of the Kingston Health Coalition

I would like to be contacted by one of the Chairs in regards to making a donation to the Coalition

I would like to be contacted by one of the Chairs in regards to volunteering for the Coalition

 

I would prefer to be contacted by: E-mail Phone Fax

 

Other Comments: