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Organization Membership Form

This form is for organizational membership. If you are an individual wanting to join our mailing list please see that button at TOP of homepage. Organizational membership is free. We currently have almost 400 tobacco and cancer control national, state, and local agencies or projects that are members. What are the benefits of being an organizational member? Members are able to co-brand and distribute materials we produce. They are also eligible for direct technical assistance from us. What do we ask of organizational members? We ask that members either have expertise in, or demonstrate interest in, engaging LGBTQ populations related to cancer, tobacco, and/or general health. Are you ready to sign your organization up for membership? Then please fill out the fields below.

Please provide us with your first and last name.
Preferred Method of Communication
Please provide us with the pronouns you use to describe yourself.
  • Email
  • Text
  • Phone Call
In order to receive updates and information about the LGBT Cancer Network, we'll need your email address.
Please share the best number to reach you.
Please share the name of your organization.
Would you like to join as an organizational member of the National LGBT Cancer Network?
Please provide us with your position at your organization.
City and State (E.g. Atlanta, GA)
Is there any additional information you would like us to know?
  • {name}
User agreement for organizations: You agree not to materially alter the images provided to you by the National LGBT Cancer Network, without prior permission, with the exception of adding your own logo to those images.
Do you know someone else who would be interested in becoming a member or receiving our newsletter? Leave their email below and we'll reach out to them!

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