TOPS Coalition Membership Form July 2023 – June 2024

Membership in the TOPS Coalition of Stanislaus County  is open to any individual or organization who endorses the mission “to reduce the harmful effects of tobacco on Stanislaus County residents” and wishes to serve as a volunteer to the cause. 

Membership is free of charge and members do not receive compensation for services. Members are required to participate in at least six (6) coalition activities every year.

Coalition meetings can count for up to three (3) activities. These include subcommittee meetings, townhall meetings, and community events. 

All information is confidential and used for data, reporting, and coalition communication purposes only. 

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Membership: *
Organization/Business Name:
Name (First, Last) *
Title: 
Ethnicity: *
Required
Email Address: *
Mailing Address: *
Phone Number: *
Agency Website:
Social Media Handle(s):
Does the TOPS Coalition have permission to list you or your organization as a top member in coalition related materials, advertisements, website, and/or social media posts, as appropriate?
 *
Which best represents you/your agency?    
 *
Required
Which priority population do you serve?  
 *
Required

Which action team are you interested in joining? 

 *
Required
What skills or experiences do you possess, that would be an asset to the coalition? 
 *
Required

By submitting this application you agree to the following:

As a member of the TOPS Coalition, I endorse the mission of the coalition and pledge my participation in coalition related activities such as meetings, subcommittees, coalition sponsored-events, evaluation activities, etc. I acknowledge that, to maintain Coalition membership, I must participate in at least six (6) Coalition activities each year. These include subcommittee meetings, townhall meetings, and community events. 

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