2012 Membership Application
Thank you for completing this online membership application.

Name of Organization
Applicant #1
First Name
Last Name
Nickname
Email Address
Password
Applicant #2
First Name
Last Name
Nickname
Email Address
General Information
Address 1
Address 2
City
State
Zip
County of Residence
Licensing Agency
First Year Licensed
Check All That Apply Foster Parent
Adoptive Parent
Kinship Parent
Therapeutic Parent
Social Worker
Child Advocate
Community Partner
Other
Home Telephone Number - Please include area code. Area Code     Number
Work Telephone Number - Please include area code. Area Code     Number
I/We would like to volunteer in our community on behalf of NCFAPA. Yes No
Annual Membership Dues: Per Year 5 Year Rate
Regular Membership:  limited to adoptive parents and/or current or former foster parents licensed by the State of North Carolina and who are in good standing with NCDSS. Regular Individual:  $50.00
Couple: $75.00		 Regular Individual :  $200.00
Couple:  $300.00
Associate Membership:  available to any individual or organization in good standing with NCDSS that does not qualify under Regular Membership. Associate Individual:   $100.00
Organization: $300.00		 Associate Individual:       $400.00
Organization:  $1200.00
Please select which type of membership you want to purchase.
1-Year Full Individual$50.00
1-Year Full Couple$75.00
5-Year Full Individual$200.00
5-Year Full Couple$300.00
1-Year Associate Individual$100.00
1-Year Associate Organization$300.00
5-Year Associate Individual$400.00
5-Year Associate Organization$1,200.00
Please also consider making a tax deductible donation to NCFAPA.
$10.00 donation
$25.00 donation
$50.00 donation
$100.00 donation
Regular Membership Only:
By completing this form I certify that all of the above information is correct and that I/we are in good standing with the State of North Carolina Foster Parent Licensing Division and/or an adoptive parent.
Applicant #1: I agree
Applicant #2: I agree




We appreciate your support which enables us to fulfill our mission!
Membership dues are subject to change without notice.

The mission of the North Carolina Foster and Adoptive Parent Association
is to promote quality foster and adoptive services through collaborative
advocacy, education, resources, reunification efforts and networking. 

2609 Atlantic Avenue, Suite 105, Raleigh, NC  27604
Phone: 1-866-623-7248
Fax: 1-919-367-9302
office@ncfapa.org
Copyright © 2011




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