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Southeast Valley Tobacco Use Prevention Coalition

(SEVTUPP)

Desert Samaritan Medical Center

1450 South Dobson Road, Suite B-326

Mesa, AZ 85202

480-649-7876

480-649-7879 fax

Membership Registration

Please complete the following form. According to the Bylaws attached hereto and incorporated herein, voting privileges for eligible Coalition Members become effective two (2) months from when the registration form is received by the Coalition.

Mission Statement

The Southeast Valley Tobacco Use Prevention Coalition will promote healthier lifestyles by increasing awareness of the negative effects of tobacco and coordinating community efforts and activities.

Vision Statement

The Southeast Valley Tobacco Use Prevention Coalition, serving Chandler, Gilbert, Higley, Queen Creek and contiguous communities, will be nationally recognized for success in mobilizing a culturally diverse community that promotes a healthy tobacco-free lifestyle by transforming practices, attitudes and policies.

The Coalition will:

Collaborate to reduce service gaps and duplication;
Increase awareness of healthy lifestyles;
Reduce youth access to tobacco;
Promote tobacco-free environments;
Provide affordable, accessible, appropriate cessation programs;
Identify effective curriculum for prevention and education programs.

Southeast Valley Tobacco Use Prevention Coalition Bylaws

Name: Date:

Agency/Organization:

Address:

City: AZ Zip Code:

Telephone Numbers:

Office: Pager:

Fax: Home:

Email Address:

For purposes of maintaining a culturally diverse community Coalition, Maricopa County Department of Health Services has requested project staff report the diversity of the Coalition.

Ethnicity:

Specify "Other":

Type of Membership: for voting purposes, according to the SEVTUPP Bylaws, members must acknowledge, on this registration form, the type of membership desired in the Coalition.

Individual Membership (community member at large, not representing an agency or organization)

Organization/Agency Membership (representing an agency or organization as a member or employee of same).

Non-Voting Membership

Voting privileges become effective two (2) months after receipt of this register.

Community Represented (check all that apply):

Chandler Gilbert Higley Queen Creek

Springfield Sun Bird Sun Lakes

Other (please Specify):

I. Please describe what you would consider your personal and/or business areas of interest for involvement in the success of the Coalition Mission and Vision Statements.

II. Based upon your time availability and interests, are you willing to consider being involved in Coalition ad hoc subcommittees or task forces?
YES NO

III. Please provide the Coalition with any special areas of interest and/or suggestions you may have for increasing effectiveness of the Coalition to serve the needs of the Coalition communities.

IV. Please provide names, addresses and phone numbers of additional individuals and/or organizations that may be interested in joining the SEVTUPP Coalition.

V. Please list your affiliation with other agencies and organizations.