Membership Application

	Contact Information Please fill out your contact information below.
	Organization Name *
	Organization Website
	Address* City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code
	Phone*
	Representative to the Coalition*
	Title*
	Email*

	Economic Impact Data
	09-10 Annual Expenditure:* $
	Annual Income:* $
	Annual Attendance:*
	Number of children served by Outreach Programs:*

	Project Teams Each member organization’s representative to the Coalition will serve on one or more Project Team. Please indicate which Project Team you are interested in (up to two teams)
	Please select your Project Team(s) * Economic Impact Data Advocacy Convenings/Workshops Public Official/Media Outreach

	Membership Coalition membership is paid annually and is based on the calendar year. Fees are based on the following scale: Organizational Membership If your organization’s annual income is: $ 2,000,000 or more                                                       $100 per year $ 150,000 to $1,999,999                                                  $ 75 per year $ 30,000 to $149,000                                                      $ 50 per year $ 30,000 and under                                                        $ 25 per year Individual Membership                                                   $10 per year
	Select your Membership Level * $100 per year $ 75 per year $ 50 per year $ 25 per year Individual $10 per year
	Comments