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Please review the FASD United Affiliate Network eligibility criteria and have an authorized agent complete this form.

Affiliate Primary Contact/Authorized Agent Information

Primary Contact First Name*

Primary Contact Last name*

Job title

Primary Contact Phone number*

Primary Contact Email*

Affiliate Organization Information

We ask for this information on an annual basis per the guidelines determined by the Affiliate Executive Council. To view these guidelines, go to www.nofasaffilaitenetwork.org/membership and download the member guidelines.

Affiliate Name*

Affiliate Public Phone Number

Affiliate Public Address or PO Box

Affiliate City*

State/Province*

Zip or Postal code*

Country

Website URL*

Annual FASD Related Budget - This is used for the purposes of calculating dues.*

Number of employees*

Upload your logo here

Please provide a 1 paragraph description of your organization and the services it provides. This will be used on the Affiliate Website, Social Media and Resource Directory along with your logo. *

Your Affiliates Twitter handle

Facebook company page*

Instagram Handle

LinkedIn company page

Services Offered*

Advocacy

Training

Prevention Programming

Family Support

Support Group - Parents of Youth

Support Group - Parents of Adults

Support Group - Parents

Support Group - Self Advocates (Adults)

Support Group - Self Advocates (Youth)

Support Group - Persons in Recovery

OT (Pediatric)

PT (Pediatric)

Speech Therapy (Pediatric)

OT (Adult)

PT (Adult)

Speech Therapy (Adult)

Diagnosis (Pediatric)

Diagnosis (Adult)

Counseling (Youth)

Counseling (Adult)

Medical Care (Pediatric)

Medical Care (Adult)

Families Moving Forward Program

Math Interactive Learning Experience (MILE)

Good Buddies

Parents and Children Together (PACT)

TBRI

Research

Has your incorporation status, 501(c)3 affiliation with Government Agency, University or Tribe Affiliation changed since last year?*

If you listed Yes to the previous question, what has changed?

List Names and Email Addresses of Individuals who should be notified of Affiliate Activities, Events etc as part of your organization. Individuals who currently have access through your Affiliate account who are not listed here will be removed. For an updated list of who currently has access to the Affiliate Network under your account, please email elsworth@fasdunited.org.*