PLAN Membership Form for Organizations

Organization:

Primary Contact Person:

Address:

City/state/zip:

Tel:

Cell:

Fax:

Email:

Website:

annual membership dues (check one):

Annual Dues—Organizational Budget
$50—Up to $200,000
$75—$200,000–500,000
$150—$500,000–$1,000,000
$200—Above $1,000,000

Please check the one that best describes your organization:

Grassroots organization

Public policy advocacy organization

Service Provider

School-based group

Other:

If you work with families with children, what age groups do you serve? (Please check all that apply)

0-5 years old

6-12 years old

13-18 years old

Over 18 years old

The issues we primarily work on are: (Please check all that apply)

Child Care Quality/Affordability

Education Equity

Economic Justice

Immigrant Rights

Family Support

Other: