Register to Become a Member of the

Healthy Latin American Coalition

Please complete the following form to become a member of the Healthy Latin American Coalition (CLAS).

Healthy Latin America Coalition Registration
  1. (*) indicates required field
  2. 1. Organization Name:
  3. (*)
    This field is required.
  4. 2. Organization Contact Information:
  5. Address 1:(*)
    The address field is required.
  6. Address 2:
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  7. City:(*)
    The city field is required.
  8. State / Province:
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  9. Country:(*)
    The country field is required.
  10. Telephone (include country code):
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  11. Email address:(*)
    The email address field is required.
  12. 3. Organization Contact Person:
  13. First and Last Name:(*)
    This first and last name field is required.
  14. Title:
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  15. Telephone (include country code):
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  16. 4. What are the objectives of your organization?(*)
    The organizational objectives field is required.
  17. 5. Recommended by: (individuals wanting to join the HLAC must be recommended by an existing HLAC member)(*)
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  18. 6. Email address of existing HLAC member:(*)
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  19. To protect against spam please enter the information shown below in the box provided.
    To protect against spam please enter the information shown below in the box provided.
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