Diabetes: Together 2 Goal® Campaign Enrollment Form

For questions or troubleshooting, please contact together2goal@amga.org.

Contact Information
Organization: *
City, State: *
Name: *
Title: *
Email: *
Phone: *
Together 2 Goal® Campaign Points of Contact
Note: Depending on the size and structure of your organization, one person may serve multiple roles. Additional team members can be added following campaign enrollment.
Primary Contact: *
Title: *
Email: *
Quality Contact: *
Title: *
Email: *
Data/IT Contact: *
Title: *
Email: *
Marketing/PR Contact: *
Title: *
Email: *
Together 2 Goal® Campaign Plank Implementation
Together 2 Goal® Data Reporting
Please select your data reporting track below: *

Clear Selection

Note: AMGA members participating in the Analytics for Improvement (A4I) collaborative must select either the Core Track or Innovators Track.

Together 2 Goal® Campaign Commitment
Please select how you learned about the Together 2 Goal campaign:


Fields marked with * are required.

Your form submission WILL be encrypted using SSL to ensure your privacy.

AMGA | One Prince Street, Alexandria, VA 22314-3318
(703) 838-0033 phone (703) 548-1890 fax
image widget