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Membership Application Form
Please complete the following form for membership consideration in the LIFE Ambassadors of TEXAS. For required responses that are not applicable to your organization, submit the text "N/A".
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* Indicates required question
Name of Organization
*
Your answer
Physical Address
*
Your answer
Mailing Address
*
Your answer
Organization Main Phone Number
*
Your answer
Organization Client Website
*
Your answer
Organization Donor Website
*
Your answer
Organization Executive Director/ CEO
*
Your answer
Executive Director/ CEO email
*
Your answer
Executive Director/ CEO cell phone
*
Your answer
Chairman/President of Board of Directors
*
Your answer
Board Chair/President email
*
Your answer
Affiliations (check all that apply)
*
No other affiliations
Heartbeat International
CareNet
NIFLA
Preborn
TPCN
Christian Leadership Alliance
Save the Storks
ICU Mobile
ECFA
Other:
Required
Medical Center/ Clinic
*
Yes
No
Name of Medical Director
*
Your answer
Which medical services do you currently provide? (Check all that apply.)
*
Ultrasound
STI/STD Testing
Prenatal Care
Well Woman Care
Pre-abortion Labs
N/A - not medical
Required
How many hours per week is your primary location open to clients/patients?
*
Your answer
How many non-mobile satellite locations does the organization operate?
*
Your answer
How many mobile clinics does the organization operate?
*
Your answer
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