Early Adopter Registration Form

This form is to be completed by group leaders signing up to participate in the Community A.C.T.I.O.N. Project as an early adopter in 2016/2017.

Name of coalition/collaborative/workgroup

Leader Name

First Name

Last Name

Leader title(s) (Coordinator, Chair, Director, etc.)

Agency affiliation of leader (if applicable)

Phone

(###)

###

####

Please describe the geographical service area your group will be working in

Who will be your project facilitator (coordinating, communicating, and convening group activities) and also serving as a liaison to 2020 Mom?

Describe the infrastructure and administration of your coalition (if applicable)

We are an independent 501c3 nonprofit organization.

We have a formal fiscal sponsor relationship with a nonprofit organization.

We have an informal relationship with a parent organization or lead agency.

We are integrated into a state or local public health department.

We are a group of community members; there is no formal structure.

Other

If you answered "yes" to have a fiscal sponsor who is your fiscal sponsor? If you answered "yes" to having a partnership with a lead agency, who is your lead agency partner? If you answered "yes" to being integrated into a state or local public health department. What is the name of the health department? If you answered "other", please describe.

By clicking here, I agree that I have reviewed the ‘Project Information Packet’. I understand the expectations for participating in this Community A.C.T.I.O.N. for Moms Mental Health project, and I have garnered support for participation by my coalition.

I agree

Once you submit your application form, please submit payment for the Early Adopter Community A.C.T.I.O.N. Project. You can either pay through PayPal or check. To pay by check contact Action@2020mom.org.

Submit Payment