Name

Job Title

Agency

Email Address

Phone

Address

City

Zip Code

Type of Membership Type of Membership Organization Individual Youth (under 18 years of age)

Please select your available time for partnership activities excluding partnership meetings. Please select your available time for partnership activities excluding partnership meetings. 1-3 hours per month 4-6 hours per month More than 7 hours per month

Please select a subcommittee of choice: Please select a subcommittee of choice: Communications Advocacy Beach Sweep Membership

Acknowledgement Acknowledgement I affirm that I have read, and will adhere,to the mission and by-laws of the Tobacco Free Partnership of Broward County.