Join the Coalition 📄 Download this form Yes, we would like to sign on to the New York Family Leave Insurance Campaign! Organization* Contact Name* First Last Email* Daytime Phone* Evening Phone Fax Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Does your organization have a lobbyist in Albany?* Yes No Institutional Authorization* We hereby grant permission to the New York Family Leave Insurance Campaign to list our organization’s name on letterhead, brochures, fact sheets, and other literature used for educational and promotional purposes. Individual Authorization* I attest that I am authorized to make this decision on behalf of my organization. My organization also agrees to support the Coalition by: Setting up a meeting for our organization’s members Making phone calls to our State legislators Setting up a community meeting Writing letters to our State legislators Putting material on our newsletter/on our website Working with our constituents to setup in-district meetings with State legislators Compiling stories of family leave difficulties from our community This iframe contains the logic required to handle Ajax powered Gravity Forms.