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*
MM slash DD slash YYYY

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