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Please enter the information indicated below for the individual filling out this application.

* Organization Name:
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* Primary Contact First Name:
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* Primary Contact Last Name
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* Phone Number: (please use (555) 666-7777 format)
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Email Address:
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* Address, City, State, ZIP
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Thank you for your organization's interest in joining the California Coalition for Mental Health (CCMH). It is recommended that you read the following documents.


After reviewing the above documents and if you believe your organization qualifies and are still interested in membership please continue.

Purpose | The purpose of the California Coalition for Mental Health (CCMH) is to provide statewide leadership and a unified voice to ensure adequate, effective and appropriate mental health care and related services to improve the quality of life for all Californians.

* Does your Organization (Board of Directors) agree with this purpose?
* Membership eligibility for organizations. Please indicate your organization type:
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If applying as a statewide organization, does the organization:


Have a statewide scope

Have a formalized structure

Have goals and objectives consistent with those of the Coalition

Have a Board of Directors, Trustees or equivalent

• Has been in existence for at least one year

Choose Yes if all of the above criteria are met.

If applying as a Regional Mental Health Coalition, is the organization comprised of at least three member organizations which are, on a statewide basis, members of the Coalition? (Regional Coalitions may not have overlapping geographic territories)

Response:

Each participating organization shall be required to pay in cash or in kind as set each year by the CCMH Executive Committee. The fiscal year shall be January 1 to December 31. Does your organization agree to pay CCMH annual dues based on ability to pay (Currently $450) and quarterly meeting fees for in person meetings (about $40-60 per meeting)?

Response:
Please add additional information or comments you may have supporting your application here.
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Delegate and Alternate Contacts


Each member shall select one delegate and an alternate (if desired) to serve on the Coalition. Please list the name of your delegate, alternate (if desired) and their contact information below.

Delegate Name (first last)
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Delegate Address, City, State, Zip
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Delegate Email:
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Delegate Phone:
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Alternate Name (first last)
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Alternate Address, City, State, Zip
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Alternate Email:
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Alternate Phone:
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