Membership Application

Individual and Organizational Membership Form
Individual Applicants - Please complete this section if you are an individual member only
Your Name:	please include prefix (Miss, Mrs. Ms. Dr. Rev)
Mailing Address
City	State: Zip Code:
Phone Number
Fax Number
Email Address
Email / Newsletter List	Yes No

Organizational Applicants - Please complete this section if you are an organizational member only
Organization Name
Website
Mission Statement
Your Name	please include prefix (Miss, Mrs. Ms. Dr. Rev)
Title
Business Address
City	State: Zip Code:
Phone Number
Fax Number
Email Address
Email / Newsletter List	Yes No

All Applicants, please fill out information below
What are you or your agency's top 2 childrens' advocacy issues?
1.
2.
Please check all that apply:
Juvenile Justice Mental Health Arts and Culture Healthcare Dependency	Childcare Ages 0 thru Pre-K Public schools Private schools Afterschool programming	Recreation & Physical Activity Community Leadership
		Other