Membership Application Step 1 of 2 50% Name* TitleOrganization (if applicable)Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CountyPhone*FaxEmail* I am*a new member.renewing my membership. Membership Dues Structure Membership Categories Annual Dues Individual Adult Student $50 $25 Government Agency $200 Organization’s Annual Operating Budget Up to $100,000 $100,001 – $250,000 $250,001 - $500,000 $500,001 – $1,000,000 $1,000,001 – $3,000,000 $3,000,001 + above $50 $75 $100 $150 $200 $300 Organization TypeIndividualSchool DistrictOrganizationType*AdultStudentOrganization Budget*Up to $100,000$100,001-$250,000$250,001-$500,000$500,001 - $1,000,000$1,000,001 - $3,000,000$3,000,001 + aboveSchool District Size*1 - 500 students500+ studentsIntermediate School DistrictCollege or UniversityTotal $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name As an Individual, please check all of the following that apply: Youth Adult Volunteer Interest areas: Service learning Youth as resources Youth asset building Board training Youth development data Positive youth development As an Organization, please check all of the following that apply:Type of Organization (check all that apply): Youth program Agency that provides services to youth and/or families Nonprofit that provides services to youth and/or families Community organization Community foundation Museum Other We serve youth & adults of the following ages (check all that apply): Infant to 5 years Elementary school-aged children Middle school-aged youth High school-aged youth College-aged youth Young parents Parents of adolescents Senior citizens Other Types of services/programs your organization provides (check all that apply): Recreation Health care Faith development Sports Prevention Character/values Education Substance abuse treatment Counseling Mentoring Leadership Philanthropy Parenting programs Volunteering/service After school care Arts/music Outdoor activities Foster care Theatre Adoption Financial assistance Job training Other Interests in training & technical assistance: (Check all that apply. We will be glad to follow up with you to talk about your current or future needs.) Positive youth development Continuous improvement Financial management Survey development Identifying funding sources Fund development Evaluation Proposal writing Liability management Strategic planning Marketing programs & services Performance evaluation Youth program development Caring school climate Hiring & training staff Youth environment mapping 40 Developmental Assets Customer service Utilizing youth development data Service learning for youth Customer analysis Strength-based youth development Board development Parent involvement Building assets in youth Other NameThis field is for validation purposes and should be left unchanged.
