Complete this form to add your organization as an official member of the Act for Women campaign. Campaign members agree to:

  • Endorse the Women’s Health Protection Act
  • Allow the Act for Women campaign to list their organization publicly as a member
  • Use and promote the Act for Women campaign brand and logo
  • Disseminate information on the Act for Women campaign and the Women’s Health Protection Act to their constituencies, as appropriate
  • Participate in Act for Women campaign activities and actions, as appropriate

Organization Name

Contact Name

Contact Email

City
State



At what level of government does your organization work? Please select all that apply.
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