"*" indicates required fields

Name of Center*

Address*

Street Address Address Line 2 City ZIP Code

Your Name*

First Last

Title*

Phone (Work)*

Phone (Mobile)*

Fax

Phone (Emergency)*

Email*

Website*

Your CAC's Facebook page URL

Your CAC's Twitter handle

Briefly describe how your Child Advocacy Center meets the ten NCA Standards:

Multidisciplinary Team:*

Diversity, Equity, and Access of Services*

Forensic Interviews:*

Victim Support and Advocacy:*

Medical Evaluation:*

Mental Health:*

Child Safety and Protection*

Case Tracking:*

Organizational Capacity:*

Child-Focused Environment:*

List any Corollary Services:*

Ex: Body Safety Program, Stewards of Children

Strengths your CAC can bring to the Chapter:*

Number of forensics interviews provided in previous calendar year:*

National Children’s Alliance (NCA) Membership Status:*

Affiliate

Associate/Development

Accredited

Non-Member

Agency*

Your Dues Total*

I would like to pay…*

Online (includes processing fee)

By check/mail

If paying by check/mail, an invoice with instructions for payment will be emailed to you after submitting this application.

Total Due

Price: $0.00

Total Due

Price: $0.00

Credit Card

Card Details

Cardholder Name

Electronic Signature*

By electronically signing and submitting this document, you are affirming your authority to submit this application on behalf of your Center and that everything stated herein is true and accurate to the best of your knowledge.

Date*

Phone

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