Connect Life WI Application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name of Organization *Physical Address of Organization *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCounty *Mailing Address of Organization (if different from above)Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutOrganization Email *Client Website / URL *Organization Phone *Donor Website / URL *Staff Information LayoutExecutive Director NameExecutive Director Phone *Client Services Director Name *Board Chair / President NameExecutive Director Email *Executive Director Date of Birth *Client Services Director Email *Board Chair / President Email *Medical Center / Clinic *YesNoName of Medical DirectorLayoutName of Nurse ManagerNurse Manager Email *Other Affiliations (Check All That Apply)Heartbeat InternationalCare NetECFALife Matters WorldwideNIFLANo Other AffiliationsServices Provided Check which services you currently provide: *Pregnancy testsUltrasoundsMaterial assistanceParenting/Life Skills classesAdoption referralsPost-abortive healingAbortion pill reversalMen’s ministryOutreach to local schoolsSTI/STD TestingSTI/STD TreatmentPrenatal CareOther services you provide that are not listed above.Satellite Office Locations How many satellite office locations do you have?Satellite Address (1)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSatellite Address (2)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMobile Units LayoutHow many mobile units do you have?Cities and counties where you use your mobile unit(s)Budget Please select the budget level for your ministry *Up to $50,999$51,000 to $100,999$101,000 to $150,999$151,000 to $200,999$201,000 to $250,999$251,000 to $300,999$301,000 to $350,000$351,000 to $499,999$500,000 and aboveAs an affiliate of Connect Life WI, our agency or organization subscribes to the principles of the coalition and its Standards of Affiliation. We recognize that Connect Life WI may revoke affiliate status, if in the opinion of the coalition, any affiliate fails to meet the Standards of Affiliation. Please complete the following to confirm your agreementWe have read, and our organization is in agreement and compliance with, the Statement of Faith of Connect Life WI.SecondWe have read, and our organization is in agreement with, the Connect Life WI Standards Of Affiliation. ChoiceSignature of Executive Director *Clear SignatureDate *Submit
