Hawaii Immunization Coalition, Protecting Hawaii's Families

Annual Hawaii Immunization Coalition Membership Form

We would love to have you join our teams!
To join the Hawaii Immunization Coalition, complete
the fillable membership form below and click Submit.
A representative of the coalition will contact you.



Membership Form
Name :-
Title :-
Organization :-
Email address :-
Mailing address :-
City/State/Zip:-
Phone :-
Fax :-
Membership :- HIC annual membership is $10 payable by check or purchase order to Hawaii Immunization Coalition, PO Box 25665, Honolulu, HI 96825. Members will receive immunization information and alerts via email and discounts to HIC workshops and seminars.
Current areas of interest and/or responsibility in immunization (ie. health education, data collection and reporting, clinical services, special population groups):
Are you a vaccine provider?:- Yes No
How did you hear about HIC?

In order for HIC to be effective, we need your active participation. Working team members make everything happen. Please select one or more of the teams below in which you will actively participate.
Infant Team : This team focuses on immunization issues for children 0-5 years
Adolescent : This team focuses on immunization issues for young adults ages 11-18
Adults : This team focuses on immunization issues for adults 19 years of age and older.


Volunteers are needed in all capacities. Please indicate how you will be willing to help:
Staff a shift at a health fair booth
Provide In-Kind contributions
Assist with HIC fundraising (printing, meeting space, etc.)
Assist with legislative issues
Help recruit members
Help with Research
Help recruit volunteers
Assist with Public Relations
Serve as HIC Spokesperson
Assist with Marketing
Assist with HIC website content