Membership Application — Los Angeles County Perinatal and Early Childhood Home Visitation Consortium

Section I

Organization Name

Organization Website

http://

Organizational representative(s) to the Consortium, authorized to speak on behalf of the organization:

Representative(s) name:

Representative(s) telephone:

Representative(s) email:

List areas where your organization works:

Specific Cities/Zip Codes:

Section II

Please read the Consortium’s Charter and 2015-2020 Strategic Plan in full and read through the following statements:

- My organization understands this Charter and is ready to agree to it.

- My organization will allocate staff time to meet requirements for engagement, including additional expectations that may be set as the Consortium continues to implement its Strategic Plan (for example, participating in data collection efforts).

- My organization will make other contributions to the work of the Consortium (for example, the commitment of a percentage of a staff grant writer’s time for a specified period, sharing of expertise, making connections to support the Consortium’s priorities, in-kind donations, and/or financial donations).

- The organizational representative(s) identified in Section I above is/are authorized to speak on behalf of this Member organization (for example, participate in consensus-building discussions on behalf of the Member organization as the Consortium approves annual priorities and policy agenda).

- My organization will actively participate in at least one Workgroup (The four Workgroups that are implementing the Strategic Goals are: Data, Advocacy, Best Practices, and Referrals.)

- My organization understands that it may speak on behalf of the Consortium only when empowered to do so by the Membership; explicit approval is required before a Member can present themselves as a representative of the Membership of the Consortium.

- My organization will regularly attend the quarterly meetings of the full Consortium membership.

- My organization understands that Consortium decisions are made by a facilitated consensus-building process.

- At least one member of my organization’s executive staff is able to participate in a 30-minute “orientation” phone call with the Consortium Coordinator.

Section III

My organization can commit to offering the following resources/support to the Consortium as needed (check all that apply):

Other:

Section IV

Please describe why you are interested in becoming a member of the Consortium, what you hope to gain from membership, and what your organization has to offer the Consortium (max 500 words).

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