New England Network for Child, Youth & Family Services



MEMBER ENROLLMENT FORM
FY 2008-09
This application form and the accompanying credit card payment form must be filled out and submitted online. If you wish to fill out a paper form, please print out this PDF version of the application and mail with payment to NEN.

The old membership year expires Sept. 30, 2008; the new year begins Oct. 1. Dues must be received by that date.
 
* Current membership status:
Applying for new membership    Renewing our membership
 
Organizational Information
* Your First Name:
* Your Last Name:
* Agency Name:
* Address:
* City:
* State: * Zip:   
* Phone: * Fax:
* Email:

Program
Name:
[if applicant is different from umbrella organization]
Address:
City:
State: Zip:   
Phone: Fax:
Email:
My organization has multiple sites

Main Contact Person
* First Name:
* Last Name:
* Address:
* City:
* State: * Zip:   
* Phone:
* Email:

Other Contacts
List the names and email addresses of all people in your organization who should receive regular NEN online bulletins such as Into Practice and Grantwriters' Resource.
First Name Last Name Email
   
   
   
   
   
   
   
   
   
   
   
   

Membership Dues
Dues are based on agency budget for programs/services provided to children, youth and families. Organizations incorporated in more than one state need to aggregate their budgets and pay dues accordingly.

To Become a Member:
*

Please make accompanying payment online via credit card.