Connect Life WI Application – Connect Life WI

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Connect Life WI Application

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Name of Organization *

Physical Address of Organization *

Address Line 1

Address Line 2

City

State

Zip Code

County *

Mailing Address of Organization (if different from above)

Address Line 1

Address Line 2

City

State

Zip Code

Organization Email *

Client Website / URL *

Organization Phone *

Donor Website / URL *

Staff Information

Executive Director Name

Executive Director Phone *

Client Services Director Name *

Board Chair / President Name

Executive Director Email *

Executive Director Date of Birth *

Client Services Director Email *

Board Chair / President Email *

Medical Center / Clinic *

Yes
No

Name of Medical Director

Name of Nurse Manager

Nurse Manager Email *

Other Affiliations (Check All That Apply)

Heartbeat International
Care Net
ECFA
Life Matters Worldwide
NIFLA
No Other Affiliations

Services Provided

Check which services you currently provide: *

Pregnancy tests
Ultrasounds
Material assistance
Parenting/Life Skills classes
Adoption referrals
Post-abortive healing
Abortion pill reversal
Men’s ministry
Outreach to local schools
STI/STD Testing
STI/STD Treatment
Prenatal Care

Other services you provide that are not listed above.

Satellite Office Locations

How many satellite office locations do you have?

Satellite Address (1)

Address Line 1

Address Line 2

City

State

Zip Code

Satellite Address (2)

Address Line 1

Address Line 2

City

State

Zip Code

Mobile Units

How 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 above

As 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 agreement

We have read, and our organization is in agreement and compliance with the Statement of Faith of Connect Life WI.
We have read, and our organization is in agreement with, the Connect Life WI Standards of Affiliation.
We have read, and our organization is in agreement and compliance with the Statement of Principal of Connect Life WI.
We have read, and our organization is in agreement and compliance with the Statement of Abortion Abolitionism of Connect Life WI.

Signature of Executive Director *

Clear Signature

Date *

At Connect Life Wisconsin, we are working to build a stronger voice for life through connection and collaboration amongst Wisconsin pregnancy centers. If you have any questions about this work, please write to us through the form on our contact page. Thank you. All Rights Reserved © 2022-2023, Connect Life Wisconsin.

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