CDPC Membership Form

Please complete this form to become a member of the Chronic Disease Prevention Council.
  • *As it should appear on CDPC correspondence.
  • By providing their initials, the prospective Member acknowledges that they are requesting to become a Member of the Chronic Disease Prevention Council. Each member is expected to attend at least two of the four Quarterly Meetings of Members in each calendar year. (Members may send an alternate or representative in their place)
    **If the Member is representing an organization, the Member hereby confirms, on behalf of the organization, that he/she has been duly designated by the organization to serve as its authorized representative for purposes of taking all actions of the organization in its capacity as a Member (i.e. Councils & Coalitions current Chair/Director will have voting privileges for their organization).
  • This field is for validation purposes and should be left unchanged.

Alternatively, you may download a physical form here, which you can complete and send to:

Laurel McCloskey

Chronic Disease Prevention Council

P.O. Box 3511, Albuquerque, NM  87190

(505) 463-5300

laurel@chronicdiseasenm.org

www.chronicdiseasenm.org