Home About Us Vax Facts Vaccine Resources Protecting Seniors Get Involved Donate Join Now Contact Us Join Now For more information about LAVA, check out our flyer! LAVA Membership Intake Form Organization name as you would like it to be listed Application date MM slash DD slash YYYY Your name First Last Preferred name if different from above Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneEmail Are you the primary contact for your organization? Yes No My organization wants to add an additional contact Additional contact information First Last PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Can your logo be used on communications and marketing materials? Yes No Permission will have to be obtained for each item individually Other LogoAccepted file types: jpg, png, Max. file size: 50 MB.Membership Levels and BenefitsPlease select the level of membership you would like to apply for. Note that membership is a one-year membership renewable annually. Membership levels Silent Supporter- Includes access to the weekly advocacy calls during the Louisiana legislative session and regular newsletter updates. ($150+) Promotional Supporter- In additional to the benefits of a silent supporting, promotional partners will have their name/ logo (with permission) on advocacy materials and any sign on letters. ($100+) LAVA Partner- In addition to benefits of the silent and promotional supporters, this tier of membership grants eligibility to participate on the policy steering committee and actively participate in leadership decisions. Partners may choose to include their logo/ company name or remain a silent partner. ($10,000+) Donor- Donors will receive communications and newsletters. I want to make a donation of an amount of my choosing. Additional Donation amount Any donation above the base membership level. This field is required for donor level.Total Email address(es) for newsletter Δ
