NSSC Pledge of Support & Membership Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Welcome to NSSC!

Thank you so much for joining us.

We promise, this application will only take a minute or two.

Jeanne Gore

NSSC Coordinator

Have you reviewed and agreed to NSSC's Points of Unity [https://docs.google.com/document/d/1BTWvJbbjBOq5HWeZolkjHHyLLSFgxn3vcuu9vY-B-K0/edit?usp=sharing]google.com and NSSC's Organizational Guidelines https://docs.google.com/document/d/1xfb9khOtN02WeVWC3Zi_GpUNZ9MO58Y8-Jpmz9B6rTM/edit?usp=sharing and do you pledge to support them and the NSSC? *

Yes

Required

Date: *

YYYY

First Name *

Last Name *

Phone: *

Mailing address - Address 1: *

Address 2:

City: *

State: *

Zip Code: *

Are you an Organization? *

Yes

Name of Organization (if applicable):

Organization website URL(If applicable - please email coordinator@nationalshatteringsilencecoalition.org with you logo image so we can add it to our "Shattering Silence Wall":

Please tell us a little bit about you and/or your organization. What will you bring to NSSC:

Are you an individual living with a SBD, doctor, nurse, social worker, policymaker, family member/significant other of someone with SBD, primary caregiver of someone with SBD, someone who cares who is not a family member/person with SBD? Please check all that apply. (Your individual answers to this question will not be shared). *

Person living with a SBD

Doctor

Nurse

Social Worker

Psychologist

Policy Maker

Family member/Significant other

Primary Caregiver

Someone who cares who is not a family member and/or person with SBD

If you have written a book, have a film, song/album, or other advocacy project pertaining to SBD, please check here and email coordinator@nationalshatteringsilencecoalition.org with your URL and an image so we can add it to our "Shattering Silence Wall"

Required

How did you hear about us? *

NSSC has a three tiered voluntary annual membership fee - $10 for individuals , $20 for Families, and and $30 Organizations. Please do not feel that you need to pay the fee if you are financially unable to do so. Your membership will help us raise awareness and create solutions for the humanitarian crisis faced by people with serious brain disorders and their families who suffer right along with them. All members, whether paid or not, will receive discounted rates for all of our events. You will also have voting rights within our coalition. If you are unable to pay the membership fee, feel free to skip this section. If you are able to pay it, please chose "Individual", "Family", or "Organization" and click on the link next to your choice to make your payment. Please be certain to come back to this form after you have made your payment, finish filling out this form, and hit "submit" to complete your membership.

Individual Membership: https://opencollective.com/nssc/contribute/individual-membership-34021

Family Membership: https://opencollective.com/nssc/contribute/family-membership-34022

Organization Membership: https://opencollective.com/nssc/contribute/organization-membership-35212

Are you interested in volunteering to serve on one of our committees? If yes, please go to https://forms.gle/Rw5NF7mGn7xKPXMr6 to sign up today. *

Yes

Further comments welcome:

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Open Collective Foundation.

Forms