AGENCY MEMBERSHIP FORM
PLEASE ONLY COMPLETE IF A REPRESENTATIVE(S) FROM YOUR ORGANIZATION HAS ATTENDED AT LEAST 3 MEETINGS. This form verifies that your organization/agency has had representation at no less than three Children's Council meetings in the past twelve months and agrees to become a member agency with voting rights. To maintain agency voting status, there must be representatives from your agency who, collectively, attend a minimum of three meetings in a twelve month period.
Date:
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DD
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YYYY
Organization/Agency:
Your answer
Web Address:
Your answer
Mailing Address:
Your answer
Age Group Served - Please indicate all that apply and provide explanation if "other".
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