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MHA-M Membership Application
Thank you for your interest in joining us at MHA-M!
Contact Information
Name of Member
*
First Name
Last Name
Name of Organization (If Organizational Member)
Alternative Representative Name (If Organizational Member)
First Name
Last Name
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Phone
*
Email
*
Verify Email
*
What is your interest in issues related to mental health?
What type of Organization?
Unincorporated Organization
Corporation
Government Entity
For Profit Organization
Nonprofit Organization
Other
What type of Nonprofit?
IRS 501c(3) Charitable
Public/ Governmental
Faith-Based
Other
Suggested Levels of Membership/Support
*
$25 - Individual Member
$35 - Family Member
$50 - Nonprofit Organization
$100 - Corporate Gift
$250 - Friend of MHA-M
$500 - Patron
$1,000 - Sponsor
$2,000 - Circle of Excellence
How will you be paying?
*
Online
Check
How much will you be paying?
$25
-
Individual Member
$35
-
Family Member
$50
-
Nonprofit Organization
$100
-
Corporate Gift
$250
-
Friend of MHA-M
$500
-
Patron
$1,000
-
Sponsor
$2,000
-
Circle of Excellence
$
Add 3% to my total amount to help cover the payment processing fees
