Membership Application
Surname
Other names
Address
City
State
Zip Code
Country
Sex
Phone
Fax
E-mail
1. Does the organization have tax exempt status under the Internal Revenue Code?
If yes, please indicate the exempt status:
If no, please list name of fiscal agent:
2. Does the organization provide non-residential community-based youth services?
Yes
No
3. List the age range for the organization's services:
to
4. Total organizational budget:
Youth services budget:
For fiscal year ending:
Fiscal year begins in:
and ends in:
5. What percentage of the organization's budget is used for:
Programs/Services
%
Administration
%
Fundraising
%
6. Indicate the direct services provided to youth and/or their families with the number of clients served annually by each program:
Direct Service
Annual # of Clients Served
Direct Service
Annual # of Clients Served
Direct Service
Annual # of Clients Served
Direct Service
Annual # of Clients Served
7. Please list the geographic area(s) served by your youth programs.
8. Please indicate how youth are referred to your youth programs.
9. Are youth and their families attending your programs voluntarily?
Yes
No
If no, explain circumstances:
Checklist of required supporting materials to enclose:
Current years income and expense budget for overall organization and highlighted youth services budget.
Most recent audited financial report or IRS 990
Two letters of support from community youth service providers which demonstrates a working relationship
Letter of Determination from IRS, or letter of agreement with fiscal agent
Application form signed by Director or Board Chair
Agency and/or Program brochure
Comments:
By signing this application for membership I am stating that all the information on this application is true, that I understand the membership dues structure, and if my organization is selected for membership, agree to pay the annual dues agreed upon with the Executive Board of the Minnesota Youth Intervention Programs Association.
Signature of Director or Board Chair
Date
