DVAC Membership Application Delaware Valley Adoption Council Application for Membership Section One: Agency/Group/Individual Information Date of Application: Agency/Group/Individual Name: Address: Phone: Website: Contact Person: E-mail: Is your agency or Group part of a larger organization? Yes No If “yes”, please explain: Section Two: CHOOSE TYPE OF MEMBERSHIP (Please complete the section that applies.) Choose Type Of Membership * 1. Sponsor Membership 2. Associate Membership 1. Sponsor Membership - Sponsor membership shall be available only to agencies and groups in Pennsylvania, New Jersey and Delaware that have an interest in adoption. An agency that is a Sponsor Member must be a provider of direct services related to adoption issues. The agency must be currently so licensed or authorized within its respective state to deliver adoption services, must have been licensed or authorized for a minimum of one year, and must support adoption as one alternative for permanency for children who cannot live with their biological families. • State adoption licenses: Pennsylvania New Jersey Delaware •Number of staff employed in Delaware Valley Area? •Date group or chapter started: (if applicable) •Type(s) of adoption currently facilitated: Private Special Needs/Foster Adoption International 2. Associate Membership - Associate membership shall be available only to agencies/groups/individuals not eligible for sponsor membership, who have a purpose compatible with permanency through adoption and are engaged in the delivery of adoption-related services and/or concerned with adoption-related issues. •Number of members in your group or chapter: •Date group or chapter started: (if applicable) Describe your adoption related services or interest related to adoption: Service or represent families/individuals in: PA NJ DE Service or represent families/individuals in: Private Special Needs/Foster Adoption International SECTION THREE: EXPLANATION AND CERTIFICATION Please write a paragraph explaining why you wish to become a member of the Delaware Valley Adoption Council. * Please check that you understand that DVAC member agencies are encouraged/expected to attend regular training/member meetings that occur 10 times a year, and are required to have at least one individual participate on one of the five DVAC sub-committees (Membership, Nominating, Legislative, Education/Training, or Public Relations). Signature of Agency or Group Representative signature keyboard Clear By signing I certify that all of the above information is true and accurate. I realize that providing false or misleading information may lead to rejection or termination of membership in the DVAC as described in Article 2, Section 2.11 of the DVAC’s Bylaws. Captcha Submit If you are human, leave this field blank.
