MEE Community Network Membership Sign-up Form

Community Network Members MUST be affiliated with a non-profit organization (i.e. Community-Based Organization). Exceptions may be granted upon MEE's approval.

Please verify your contact information below and submit this form
or print and fax it to (215) 829-4903.

Fields marked with * are required
Job Title*
Prefix*  (Rev., Prof., Past., Ms., Mrs., Mr., Hon., Dr.)
First Name*
Last Name*
Nearest Metro Area*
Choose Metro Area
from list on right
and type in space provided above
Birmingham Alabama
Huntsville Alabama
Mobile Alabama
Montgomery Alabama
Anchorage Alaska
Fairbanks Alaska
Phoenix Arizona
Tucson Arizona
Fayetteville Arkansas
Little Rock Arkansas
Memphis Arkansas
Bakersfield California
Fresno California
Los Angeles California
Oxnard California
Riverside California
Sacramento California
San Diego California
San Francisco California
San Jose California
Boulder Colorado
Colorado Springs Colorado
Denver Colorado
Fort Collins Colorado
Hartford Connecticut
New Haven Connecticut
New York City Connecticut
Norwich Connecticut
Stamford Connecticut
Wilmington Delaware
Dover Delaware
Ft. Lauderdale Florida
Gainsville Florida
Jacksonville Florida
Miami Florida
Orlando Florida
Pensacola Florida
St. Petersburg Florida
Tallahassee Florida
Tampa Florida
Atlanta Georgia
Augusta Georgia
Savannah Georgia
Columbus Georgia
Honolulu Hawaii
Boise City Idaho
Chicago Illinois
Peoria Illinois
Springfield Illinois
Fort Wayne Indiana
Gary Indiana
Indianapolis Indiana
South Bend Indiana
Evansville Indiana
Cedar Rapids Iowa
Des Moines Iowa
Kansas City Kansas
Wichita Kansas
Lexington Kentucky
Louisville Kentucky
Baton Rouge Louisiana
Lafayette Louisiana
New Orleans Louisiana
Shreveport Louisiana
Portland Maine
Baltimore Maryland
Hagerstown Maryland
Washington, D.C. Maryland
Boston Masachusetts
Springfield Masachusetts
Worcester Masachusetts
Ann Arbor Michigan
Detroit Michigan
Flint Michigan
Grand Rapids Michigan
Lansing Michigan
Duluth Minnesota
Minneapolis/St. Paul Minnesota
Jackson Mississippi
Kansas City Missouri
Springfield Missouri
St. Louis Missouri
Billings Montana
Bozeman Montana
Lincoln Nebraska
Omaha Nebraska
Las Vegas Nevada
Reno Nevada
Manchester New Hampshire
Atlantic City New Jersey
Camden New Jersey
Newark New Jersey
Trenton New Jersey
Albuquerque New Mexico
Las Cruses New Mexico
Santa Fe New Mexico
Albany New York
Buffalo New York
New York City New York
Rochester New York
Syracuse New York
Charlotte North Carolina
Durham North Carolina
Greensboro North Carolina
Wilmington North Carolina
Winston-Salem North Carolina
Raleigh North Carolina
Bismark North Dakota
Fargo North Dakota
Grand Forks North Dakota
Akron Ohio
Canton Ohio
Cincinnati Ohio
Cleveland Ohio
Columbus Ohio
Dayton Ohio
Toledo Ohio
Youngstown Ohio
Oklahoma City Oklahoma
Tulsa Oklahoma
Eugene Oregon
Portland Oregon
Salem Oregon
Allentown Pennsylvania
Erie Pennsylvania
Harrisburg Pennsylvania
Harrisburg Pennsylvania
Lancaster Pennsylvania
Philadelphia Pennsylvania
Pittsburgh Pennsylvania
Reading Pennsylvania
Reading Pennsylvania
Scranton Pennsylvania
Newport Rhode Island
Providence Rhode Island
Charleston South Carolina
Columbia South Carolina
Greenville South Carolina
Spartanburg South Carolina
Sioux Falls South Dakota
Pierre South Dakota
Chatanooga Tennessee
Knoxville Tennessee
Nashville Tennessee
Memphis Tennessee
Amarillo Texas
Austin Texas
Beaumont Texas
Corpus Christi Texas
Dallas Texas
El Paso Texas
Houston Texas
Lubbock Texas
San Antonio Texas
Waco Texas
Ogden Utah
Provo Utah
Salt Lake City Utah
Burlington Vermont
Montpelier Vermont
Arlington Virginia
Roanoke Virginia
Richmond Virginia
Virginia Beach Virginia
Seattle Washington
Spokane Washington
Tacoma Washington
Charleston West Virginia
Huntington West Virginia
Green Bay Wisconsin
Madison Wisconsin
Milwaukee Wisconsin
Casper Wyoming
Laramie Wyoming
Work Phone
Please include area code
Work Fax
Please include area code
Choose Username*
Do not use Email Address as User Name
Choose Password*
What type of organization
do you work at?
Advocate/Activist Adult Education
After School Program Arts and Performing Arts
City Government Community Development
Advocate/Activist County Government
Criminal Justice/Law Enforcement Elementary School
Faith-Based/Church Federal Government
Foundation/Fund Halfway Homes/Group Homes
Health Clinics Health Department
High School Hospital/Managed Care Facility
Media (Radio, TV, Print) Medical School
Middle School Prison (Correctional Facility)
State Government Trade School
University/College/Community College

Who does your
organization serve?

Adult Adolescents/Youth
Asian/Pacific Islander Bisexual
Black (African American) Blind (Visually Impaired)
Deaf (Hearing Impaired) Gay and Lesbian
Homeless Latino/a (Hispanic)
Men Native American
Seniors Teens/Young Adults
Transgendered White (Caucasian)
What services does your
organization provide?
African/African American History
After School Activities
Alcohol Abuse Prevention
Care and Primary Care
Child Abuse Prevention
Computer Training/Web Design
Domestic Abuse/Dating Violence Prevention
Education Services
Gun Violence Prevention
Homeless Services and Shelter
Housing Services
Job Training/Employment Assistance
Learning Disability Services
Mental Disability Services
Mental Health Wellness Services
Obesity Prevention
Parenting Services/Early Childhood Development
Physical Activity and Nutrition
Physical Disability Services
Prenatal Services
Public Policy
Reproductive Health Services
Sexual Assult Services
Sexual Education
Smoking Prevention
Sports and Recreation
STD/STI Prevention and Treatment
Substance Abuse Prevention
Substance Abuse Treatment
Support Group/Support Services
Technical Assistance
Violence Prevention
Welfare/Government Assistance

What MEE services and
campaign activities
would be of interest to you?

HIV/AIDS Campaigns
Focus Group Research
Violence Prevention Campaigns
Substance Abuse Campaigns
Sexual health Issues
Workshops/Trainings/Technical Assistance
Smoking Prevention Campaigns
Entertainment Campaigns
Dating/Domestic Violence
Education Related Campaigns
Mental Health Wellness Campaigns
Obesity prevention Campaigns
Survey Research