CCMH Membership Application
RequiredRequired Question(s)
Required 1.
Please enter the information indicated below for the individual filling out this application.

First Name:
Last Name:
Company Name:
Work Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

Required 2.

 

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:


CCMH Bylaws

CCMH Agenda for Fairness


Are you still interested?  


YES
NO
3.

 

California Coalition for Mental Health (CCMH) The Purpose of the Coalition 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?


YES
NO
  • Comment:

  • 500 characters left.
4.
Membership eligibility for organizations. Please indicate your organization type:

a) An organized and recognized advocacy group or a statewide professional organization with a special interest in, and commitment to, Mental Health Advocacy
b) A Regional Mental Health Coalition comprised of local units of the constituent organizations of the Coalition
c) Entities not meeting requirements for full membership in the Coalition may request an affiliate, no-voting, membership. Acceptance of Affiliate Members requires a two-thirds majority vote of the Coalition at its next regularly scheduled meeting.
Other  
5.

If applying as a statewide organization, does the organization: 

 

(1) have a statewide scope,  

(2) have a formalized structure  

(3) have goals and objectives consistent with those of the Coalition,  

(4) have a Board of Directors, Trustees or equivalent, and  

(5) has been in existence for at least one year? 

 

Select YES only if ALL OF THE ABOVE

YES
NO
6.

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)

YES
NO
7.

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 (up to $450) and quarterly meeting fees (about $40-60 per meeting)?

YES
NO
8.

Please add additional information or comments you may have supporting your application here.

 

350 characters left.

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. 

 
Required 9.

Name of Delegate

 

50 characters left.
Required 10.

Mailing Address of Delegate

 

350 characters left.
Required 11.

Phone Number of Delegate

 

50 characters left.
Required 12.

Email Address of Delegate

 

50 characters left.
You may also designate an alternate (optional). If desired, fill in the information below.
 
13.

Name of Alternate

 

50 characters left.
14.

Mailing Address of Alternate

 

350 characters left.
15.

Phone Number of Alternate

 

50 characters left.
16.

Email Address of Alternate 

 

50 characters left.