Cover Alabama Coalition Sign-on
If you share our mission and principles outlined below, please complete this form to officially join the Cover Alabama Coalition. Our steering committee reviews sign-on requests once a month. We will include your organization logo and/or name in our membership list that will be hosted on the website and used publicly from time to time.

******THIS SIGN-ON FORM IS FOR ORGANIZATIONS ONLY******

If you would like to join us as an individual, please sign our petition here: https://p2a.co/N1UWZw2 
Sign in to Google to save your progress. Learn more
Mission:
The many organizations that make up the Cover Alabama Coalition are committed to ensuring that Alabama closes the coverage gap in a way that meets the needs of the nearly 300,000 Alabamians who would become eligible for Medicaid expansion coverage, while protecting the state’s 1 million current Medicaid members.
Principles:
THE COALITION BELIEVES IN:

Maximizing the federal investment in Alabama’s health care
The availability of quality, affordable health coverage for every Alabamian
Protecting current Medicaid members and services
Ensuring a common-sense system that meets consumers’ needs and limits additional administrative hurdles and costs

If you share our mission and principles, please fill out this form to formally join the Cover Alabama Coalition.

You can view the Coalition’s full policy agenda here: https://adobe.ly/32lJSP4

Note: Our guiding principles will be listed prominently on the Cover Alabama Coalition website and other public facing documents. The policy agenda will be included on the website as a PDF on the ‘About Us’ page.

Organization Name *
Please enter your organization name exactly as you would like it to appear on Coalition materials. If your organization includes an abbreviation, please spell it out completely.
Organization Contact - First Name *
Organization Contact - Last Name *
Organization Contact - Email address *
Organization Contact - Phone Number *
Organization Contact - Address *
Please select a committee below, if interested.
Note: it is not required to serve on a coalition committee.
About how many Alabamians does your organization represent?
Second Organization Contact - First Name
Only complete this section if you would like to add a second organization contact to receive Coalition communication.
Second Organization Contact - Last Name
Second Organization Contact - Email address
Second Organization Contact - Phone Number
Please select a committee below for your Second Organization Contact, if interested.
Note: it is not required to serve on a coalition committee.
Are you authorized to sign on behalf of your organization? *
Organization Logo - Please send your organization's logo in PNG (*preferred), EPS, and/or JPEG format to coveralabama@alarise.org once you submit this form.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of alarise.org. Report Abuse
Google Forms