Membership Application

Membership Overview

If working together to eliminate tobacco-related and cancer health disparities in low socioeconomic populations with like-minded individuals, nonprofits, business and organizations nationwide is of interest to you, you are the perfect candidate to join our network. Please fill out this initial application to get started.

Membership Interest Form

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Please Tell us More About your Organization:

Target Population Served (select all that apply) *

Annual household income less than or equal to 250% of the current Federal Poverty Level (FPL)
Fewer than or equal to 12 years of education (GED or high school diploma is the highest level of educational attainment)
Uninsured or limited medical health insurance (e.g. underinsured) Unemployed or “underemployed” (e.g. seasonal, temporary status)
Recipient of a federal or state sponsored government program (e.g. Medicaid, WIC, affordable or subsidized housing recipient, Supplemental Nutrition Assistance Program (SNAP), etc.)

Please share with us your organizational mission and how this is synergistic with the SelfMade Health Network. *

Additional Contact Information

Additional Organizational Contact (First and Last Name)

Email for Additional Contacts

Additional Organizational Contacts (First and Last Name)

Email for Additional Contact

Additional Space or Inputting More Contacts (If needed)

Membership Overview

Membership Interest Form

Please Tell us More About your Organization:

Additional Contact Information

Network member News

SelfMade Health Network and Meharry Medical College Address Disparities

University of KY receives acclaim for work in lung cancer prevention and survivorship

National Colorectal Cancer Roundtable (NCCRT) Recognizes Leaders in Colorectal Cancer Screening Efforts with 80% by 2018 National Achievement Award

Membership Interest Form

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