Did you fill out an application in the last two years? You may be able to edit your prior application and pay your dues for this year. Check if your application is available.

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Name of Center*

Address*

Street Address Address Line 2 City ZIP Code

Your Name*

First Last

Title*

Phone (Work)*

Phone (Mobile)*

Email*

Fax

Website*

Your CAC's Facebook page URL

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:*

Case Review:*

Case Tracking:*

Organizational Capacity:*

Child Safety and Protection*

List any Corollary Services:*

Ex: Body Safety Program, Stewards of Children

Strengths your CAC can bring to the Chapter:*

Number of forensic 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.

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*

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