Membership Application

Please submit this form to join IACP as a Global Partner.

Your Contact Information

First Name *

Last Name *

Email *

Phone

By checking this box, I consent to receive transactional messages related to my membership account or services I have requested. These messages may include renewal reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

Organization Details

Partner Name *

Partner Organization Type *

a United States 501(c)3 nonprofit

a Non-Governmental Organization with nonprofit status in our home country

a Collaborative Practice group

other

My organization supports IACP’s mission. *

Yes

You can learn about IACP's Mission at https://collaborativepractice.com/about-us

We are willing to commit to working together with other Global Partners to promote the availability of Collaborative Practice around the globe. *

Yes

We are willing to commit to creating alliances and maintaining a strong reciprocal working relationship with IACP and other Global Partners. *

Yes

How does the mission of your organization align with IACP's mission? *

How will you distribute IACP’s Forum and other event announcements? *

Partner Logo *

Partner Street Address *

Partner State or Province *

Partner Postal Code *

Partner Country *

Partner Website

Name to list for Public contact *

Email to list for Public contact *

Admin Contact

This contact will receive the Dues Invoice.

Admin Contact First Name *

Admin Contact Last Name *

Admin Contact Email *

Membership Designee

This person will have access to the member portal.

Membership Designee First Name *

Membership Designee Last Name *

Email *

Job Title *