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! 2023 LAVA Membership Application Your name(Required) First Last Preferred name if different from above Organization name as you would like it to be listed Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Are you the primary contact for your organization?(Required) Yes No Please add an additional contact Additional contact information First Last Additional Contact PhoneAdditional Contact Email Additional Contact Mailing AddressIf different from primary contact mailing address. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code If you are an organizational member, 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(Required) FRIEND- Access to the LAVA newsletter and advocacy events during legislative session and throughout the year. Min $50 donation PARTNER-- Friend benefits plus access to weekly advocacy calls during the legislative session, proud partner sticker, and proud partner electronic button. Min. $500 donation LEADER-- Partner benefits plus participation on LAVA's Policy Steering Committee, opportunity to particiate in leadership & strategy discussions, and logo/ compnay name on LAVA website if requsted. Min. $10,000 donation DONATION ONLY Additional Donation AmountPlease add any additional donation above the minimum for the membership level selected. Total Email address(es) for newsletterHow did you hear about the Louisiana Vaccine Alliance?(Required) Why are you interested in joining the Lousiana Vaccine Alliance?(Required) Certification(Required) I certify that I have no malicious intent in joining the Louisiana Vaccine Alliance and that I will support the mission and goals of the Alliance to the best of my ability Δ
