CHIP Chapter Participation Form
Purpose: To intake chapters into the CHIP program; to collect preliminary and basic health assessment data from chapters; to orient chapters around things they need to have in terms of their development.

Submission Frequency: Once per chapter

If your chapter participated in CHIP in 2017-2018, click the link below to submit an abbreviated version of the form:

https://docs.google.com/forms/d/e/1FAIpQLScUxeMcwFlZq0Zn7evjLOVyt7meBSTopcC5qh8K6g38YbezJA/viewform?usp=sf_link

Email address *
Chapter Status
Question 1: Chapter Name *
Question 2: Chapter Street Address/PO Box *
Question 3: City *
Question 4: State *
Question 5: Zip Code *
Question 6: Region *
Question 7: Chapter President’s Name *
Question 8: Chapter President’s E-mail *
Question 9: EIN/Tax ID Number
Question 10: Does the chapter have an active bank account? *
Question 11: Does the chapter intend to submit the NSBE GEN Survey this year? *
Note: The NSBE GEN Survey can be found under "My Activities/Complete a Survey" in your NSBE Connect member account.
Question 12: Select chapter offices that are currently filled on your chapter executive board *
Required
Chapter Communications
Question 13: Attach an electronic copy of the chapter’s most current version of its governing/founding document (Constitution or Bylaws) *
Required
Select the media sources that your chapter currently uses *
Required
Website URL
Facebook URL
Twitter Handle
Instagram Handle
LinkedIn URL
Annual Plan
Question 14: Attach an electronic copy of the chapter’s goals for the coming year. Make sure that the goals specify measures and targets. (i.e., it must be clear what success looks like.) *
Required
Question 15: Does the chapter collect local dues? *
Question 16: How much is charged for local dues? (Enter N/A if local dues are not charged.) *
Chapter Budget
Question 17: Has the chapter developed a budget for the year? *
Attach a copy of the chapter’s budget for the year.
A copy of your responses will be emailed to the address you provided.
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