Arkansas Coalition Against Domestic Violence :: Individual Membership Application

People seeking membership in the Arkansas Coalition Against Domestic Violence (ACADV) must complete the following application. Please answer all questions completely.

1.	Name
	Profession
	Address
	County
	Phone
	Fax
	Email Address
	Please check your preferred method of communication.	Phone Fax Email
2.	Why are you interested in becoming a member of ACADV?
3.	Name of domestic violence program nearest you.
4.	Do you have any affiliation with this program?	Yes No
	If yes, please describe.
5.	You will receive the ACADV newsletter at the above email address unless you check the box to have it mailed to you.	Yes, please mail the newsletter to the above address.
PRINCIPLES OF UNITY
	The members of the Arkansas Coalition Against Domestic Violence recognize that the struggle of each battered woman we serve is related to our individual struggles for personal growth and empowerment. We are committed to the ideas and practices of a supportive, non-competitive atmosphere in all aspects of our programs that fosters open communication, respect and cooperation among all members of the Coalition. We support and encourage and will work for the participation of all battered women regardless of race, ethnicity, sexual orientation, age, income or physical challenges. I have read and agree to adhere to the Principles of Unity of the Arkansas Coalition Against Domestic Violence and hereby apply for Supportive Membership on this day of , 20 . Signature: By submitting this form you are digitally signing the agreement with the name in the box above.

Angels of Grace Director Gracie Gonner 406 Pecan St Helena AR 72342	Phone: 870-338-8447 Fax: 870-572-5755 Hotline: Local 870-572-9530 Toll Free 877-572-9530 Email: ggonner0614@yahoo.com