Core Member Application

Name of Family-Run Organization

Address

Website

Type of Organization

Is the organization's board comprised of at least 51% parents or caregivers of children with emotional, behavioral or mental health needs?

Is the organization designated as a 501C3 organization?

Organization's Mission Statement

Name of Executive Director/CEO

Current Role/Title

Please Check Appropriate Category Regarding Your Current Role

Full time Executive Leadership

Part time Executive Leadership

If You Are The Current Executive Director, Years in Position

If Part Time, Describe Other Employment

Are You Now or Have You Been a Caregiver of a Child with Mental Health Needs?

Work Email

Work Phone

Cell Phone

Please upload the following items with your application: 1. IRS Letter of Determination as a 501c3 non profit 2. Current list of Board of Directors (including their role/representation) 3. Agency brochure

Drop files here or

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