Member Application

ONLINE MEMBERSHIP APPLICATION FORM

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We invite you to become a member of the Older Adult Consumer Mental Health Alliance as we strive to improve the nation's response to the mental health needs of it's older citizens. With acceptance of your application for membership, we encourage you to participate in our organization's committees, educational opportunities and advocacy activities. As part of the application process, please indicate your area of expertise and interest in the committee list. Complete the online membership application then mail your payment for annual or lifetime dues to: Bryce Miller, Treasurer, at 2548 SW Belle Avenue, Topeka, KS 66614-1753. Your membership will become effective once your dues have been received and you will be notified by return mail or email. Your interest, advocacy and expertise to further this most worthy cause is needed. You need the Alliance and the Alliance needs you. Tax exempt contributions in any amount can be made to the Alliance by contacting Bryce Miller, Treasurer, at 2548 SW Belle Avenue, Topeka, KS 66614-1753. or e-mail ksbryce@aol.com .

If you wish to complete a paper application and mail your application and dues to the Alliance click here.

Please provide the following membership information:

      First Name 
       Last Name 
  Middle Initial 
           Title 
    Organization 
  Street Address 
 Address (cont.) 
            City 
  State/Province 
 Zip/Postal Code 
         Country 
      Work Phone 
      Home Phone 
             FAX 
          E-mail 
             URL

Choose one of the following options:

Consumer and/or Family/Care Giver ($10 annual or $100 Lifetime)
Non-Consumer ($25 annual)
Family (Non-Caregiver) ($20 annual)
Professional ($25 annual)
Organization ($ 100 less than $500,000 budget, $200 over $500,000)
Select any of the following options that apply:

Membership and Chapter Coordination
Funding and Resource Development
Education and Communication
State and Local Chapter Organization
Advocacy/Legislation and Political Action

E-mail the Webmaster with comments and questions about this site Date Last Updated: 04/13/2004