NSSC Membership Registration Form

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Email *

Please enter your name - first and last *

Please enter your mailing address *

If you are joining as an organization, please enter which *

How are you affected by Serious Brain Disorders/Serious Mental Illness? *

I'm a peer.

I'm a caregiver and/or family member.

I'm a clinician.

Other

Required

Please select which ways you are willing and able to serve NSSC: *

Policy Action Committee (focus on policy change at the state and federal level)

Communications Committee (blog, website, social media, newsletter, press releases, etc.)

I have a story that I want to share in writing and have permission to share it

I have a professional talk I'd like to give to educate others

I have a peer talk I'd like to give to educate and inspire others

I want to host or help facilitate a support group

I want to attend a support group

I want to volunteer some other way

Required

How did you hear about us? *

Social Media

Online event

In-person event

Word of mouth

News

Other

To complete your registration, please go to our donate page on our website to offer a donation. This is not mandatory for your membership but encouraged as we operate as a volunteer-based organization. Link to donate: https://www.nationalshatteringsilencecoalition.org/donate.html

You are welcome to leave any further comments below. Thank you for joining the coalition, and welcome to the National Shattering Silence Coalition!

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