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Friend Membership Form
Annual Membership Fee
*
$45
Your credit card will be renewed automatically on your sign-up date to ensure your membership for the next year.
Yearly
Contact Information
Name
*
First Name
Last Name
Professional Degree / Credential Abbreviations (ie. RN, PhD, MSW, JD)
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Email
*
Verify Email
*
Phone Number
*
Website beginning with http://www.
Business Name
Role Description
I am joining MNDC because:
Please check all that apply
I am an aspiring death support professional
I have worked in a profession closely associated with end of life support and want to see it grow
I have benefited from end of life support services in the past
To learn more about the field of death support
To access written/published resources and information
To access online education, such as webinars, both live and recorded
To find a mentor
To get referrals from prospective clients because of being listed in the MNDC online directory
To find ways to get involved in the profession of end of life care
To network with other end of life professionals in the field
Being MNDC member lends credibility to my work
To have access to the social media closed MNDC groups (such as the MNDC Member Facebook page)
To stay current on issues in the end of life profession
It is affordable
To support MNDC and/or the emerging profession
Other
How Did You Hear About MNDC?
Please check all that apply
EOLD Training
MNDC Website
MNDC Newsletter
FaceBook Page
A Friend
Google Search
Other
I would like to be involved with MNDC as a volunteer:
Please check all that apply
I have interpersonal/leadership skills
I have organizational skills
I have media/publicity skills
I have writing skills
I have public speaking skills
I have technological skills (i.e., website or database maintenance, etc.)
I have networking skills (building bridges with individuals and other orgs.)
I have fundraising/development skills
I have administrative skills
I have free time to help
I have worked in a profession closely associated with end of life
I would be interested in serving on the board of MNDC
Other
** The information collected below is anonymous and will be aggregated so that no personal information is connected with your answers. This cumulative data is used for grant requests,
programming strategy, and diversity, equity, and inclusion efforts. Thank you in advance for your willingness to participate.
Age Range
*
Select one
select one
18-25
26-35
36-50
51-60
60+
Gender
*
Select one
select one
Female
Male
Transgender
Non Binary
Gender Variant/Non-Conforming
Other
Prefer Not to Answer
Race / Ethnicity
*
Please check all that apply
Caucasian
African American /Black
Latinx
Native American
Asian
Bi-Racial
Multi-Racial
Other
Prefer not to answer
Education Level
*
Select one
select one
Did not graduate from High School
High School Graduate or GED
Some College
College Degree
Graduate School
Professional Degree
Household Income
*
Select one
select one
Less than $10,000
$10,000 - $25,000
$25,000 - $50,000
$50,000 - 100,000
$100,000 - $150,000
Over $150,000
Prefer not to answer
Mission and Vision
*
By clicking the box below, I am indicating that I have read and understand the MNDC Mission, Vision and Value Statement.
Yes, I agree
Checkboxes
*
May we announce your membership in MNDC communications?
Yes, you may share the news of my membership in MNDC communications
No, do not share the news of my membership in MNDC communications
Add 3% to my total amount to help cover the payment processing fees
