Membership

Please tell us about yourself and your organization by completing the membership form. You may submit this form electronically by clicking the "Submit" button or printing a copy and faxing the completed form to 757.668.6475.

No fees or membership dues for participation
PIV does not sell or share your information outside of our members

Once submitted, you will receive a welcome packet with orientation information via e-mail.

Membership Form

Any field marked with a * is a required field.

Personal Information

Full Name *

Mailing Address *

City *

State *

Zip Code *

Phone *

Fax

Email Address *

Degree(s)

Organization

Job Title

Coalition Agreement

I agree to be an active member in:

Project Immunize Virginia (PIV) (statewide)
Tidewater Immunization Project (TIP) (regional/Hampton Roads)

By contributing to meetings, discussions, work groups and work towards advancing the goals and objectives of PIV/TIP.

Areas of Interest

Method of Contribution

I or the organization I represent will contribute to PIV/TIP in the following ways:

Meeting Place
Meal Provision at Meetings & Events
Financial Support
Copying and/or Mailings
In-kind Donations
Publicize projects/events in organizations newsletter or magazine

Comments Enter any additional thoughts or questions below:

Why Join PIV?

Coalition members represent organizations and companies throughout Virginia that are vested in making a difference in the health of Virginians. Each member brings a unique set of values and priorities that define the projects and contribute to accomplishing the goals of Project Immunize Virginia.

Join PIV today and help promote immunizations against vaccine-preventable diseases.

Benefits of Membership

Quarterly Meetings
Networking Opportunities
Latest Immunization Information
Monthly Tracker Talk Newsletter
Contribution towards Making Virginians Healthier