MEMBERSHIP- Enrollment FormWe need just a few more details to complete your membership. Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country County * Age * Organization Affiliation * Job Title Is your position funded through federal funds * Yes No Please select your role * System Partner (Organization that collaborates with PMHCA/Youth MOVE PA/PA Care Partnership) Provider (Provides Services and Treatment) Community Agency (A human service program at the community level) Youth (Between the ages of 14 to 29) Family (Family Member Supporting a Youth) Other/None of the Above How did you hear about our organization ? Which do you have interest in? Select as many as you would like. * Account/event specific emails only Advocacy Opportunities Job Opportunities Recovery Events Recovery Round-Up - Monthly PMHCA Newsletter Training and Education Opportunities Virtual Peer Support Group Reminders List of Services you would like to know about * Please select the type(s) of email you would like to receive from PMHCA. (You can make additional changes in your membership profile) Account/event specific emails only Advocacy Opportunities Job Opportunities Recovery Events Recovery Round-Up - Monthly PMHCA Newsletter Training and Education Opportunities Virtual Peer Support Group Reminders Are you interested in participating in a leadership role? * Yes No Would you like to be contacted as a volunteer to assist with our events? * Yes No Tell us a little about yourself and any lived experience you may have (Optional) Thank you!
