MEMBERSHIP APPLICATION - you may choose to submit brochures that contain this information.

Agency Name: ______________________________________________
Address: ___________________________________________________
Telephone Number (Main Office): ___________ Fax: ________
E-Mail: ______________________________________________
Executive Director: ___________________________________________
Types of Services Offered (an attached sheet can be completed to fulfill this requirement):
Licensing Body: ________ Licensing Capacity: _________________
Date of Accreditation: ________________ Date of Expiration: _________________
Accreditation Body: __________________________________________________

A.Dues/Fiscal Information

1. Total agency operating expenditures for the current fiscal year: $_______________
Dues.-- Dues are based on the agencies operating budget for children?s services calculated at .0044 for the first $1.5 million. of the budget, .002 for the next $1.5 million, .001 for the next $2.4 million, and a maximum of $12,000 per year.

2. New members are assessed dues at one-half of this amount for the first year of membership. The policy for new members also allows for further negotiation of first-year dues.

3. Our agency will pay membership dues:
( ) Annually( ) Semi-Annually( ) Quarterly

B.Governing Body

1.Please submit a list of your agency Board of Directors.
2.Submit your Organizational Chart and if available a staff directory.

C.Philosophy/Purpose Statement

1.Submit your agency?s mission statement/philosophy of care and letter describing interest in one or more of the services advocated for by the Coalition.
2.Submit descriptive statements which explain your:
a.Target population / age;
b.Intake criteria
c.Statement specifying client rights and procedures for grievances
d.3-5 year planning ideas (if available)
e.Annual Report (if available)
f.Other information, which will describe your agency

In doing so, the above named agency will agree to abide by the Mission of the Coalition for Family and Children's Services, the By-laws, policies and positions adopted by the Board of Directors, and the willingness to work toward the collective good of the Coalition Membership.


Executive Director's Signature


_________________________

Date submitted:  ____________