Healthy Maine Partnership/CCHC Registration Form

Hello HMPers,

Now that there are new service areas, and many fresh faces to the world of the Healthy Maine Partnerships, the Health Policy Partners of Maine (aka the Maine Coalition on Smoking or Health) wants to ensure they don't leave anyone out!  Please fill out the form below and let us know what your role is as part of your local HMP/CCHC, what topic areas you are interested in, and what you may want to be involved with in the future.

Thank you,

Becky and Amy

Name
Title  
Lead Agency 
HMP
CCHC (if applicable)
E-mail     
Mailing Address   
City, State, Zip
Telephone 
Fax

                 
What are the issues in which you are interested? (Check all that apply)

Tobacco cessation (including access and insurance)  Tobacco taxes, sales, licensing 

Secondhand smoke exposure  Youth smoking rates, access to tobacco

The Fund for a Healthy Maine Childhood obesity  Nutrition and physical fitness


Which activities would you or your organization be willing to participate? (Check all that apply)

Contacting legislators   Testifying at public hearings  Advocating in your community

Participating in events (i.e. rallies, press conferences) Other
 

Who are the state representatives for your service area?  Please enter their names here:

Senate Member(s)
House Member(s)

If you have any questions, don't hesitate to contact Amy at aolfene@portlandmaine.gov or (207) 874-8774