Membership Enrollment or Renewal

• You receive the Coalition Report Newsletter & Coalition E-lerts come to your e-mail address

• You can join our national list-serve and receive current legal, legislative and media alerts.

• Your active involvement is encouraged. You support privacy, access and quality mental health services.

Membership Levels:				National Coalition Foundation In addition to your membership contribution, you may also choose to contribute to the National Coalition Foundation. Foundation funds may be used for public education, office expenses and other essential costs that do not pertain to the Coalition’s political advocacy activities.
$10,000+	Angel	$251- 500	Reformer
$5001-10,000	Super Hero	$176- 250	Challenger
$2501- 5,000	Hero	$100-175	Advocate
$1001- 2,500	Champion	$35- 99	Supporter
$501-1000	Leader	$ 0	Consumer/Student

Dues payments may be deductible as a business expense. Please check with your tax professional.

All Foundation contributions are tax deductible as a charitable contribution..

Your enrollment information and e-mail will be used for mental health advocacy only.

YES! I want to join the National Coalition of Mental Health Professionals and Consumers, Inc.

Date:

Name:

Address:

City

State: Zip:

Fax

Work Ph. Ext.

Home Ph.

Mobile Ph.

E-Mail

Your e-mail is essential information; it is the means by which we send you news, updates and legislative alerts.

You can choose whether or not to participate in the Coalition List-Serve.

Put/Keep me on the Coalition List Serve: ____ Yes ___No

Please mark all that apply: I am ___ a Consumer or Student ___ an Elected Official ___ Clergy

___ a Mental Health Professional Discipline: __________________________ Degree: ________________

I am willing to contact legislators ____ by e-mail _____ by letter _______ by phone _______ in person

Checks payable to NCMHPC, Inc.

mail to:

NCMHPC, Inc.

P.O. Box 438

Commack, New York, 11725

Enclose Foundation donations with your

membership contribution.

Thank You!

Checks payable to NCMHPC Foundation and mail to:

NCMHPC Foundation

P.O. Box 438

Commack, New York, 11725

We Accept Visa, MasterCard & American Express You may fax credit card payments to 631-979-5293

Name on Card: __________________________________________________

Type of Card: ___ Visa ____ Master Card ____ American Express

Card #: _____________________________________Expiration Date___________

Amount to Charge: $ _________ Membership Contribution

Amount to Charge: $ _________ Foundation Donation

NCMHPC
National Coalition of Mental Health Professionals and Consumers, Inc.