Membership Application (APG) This application form is for APGs or APG staff members. APG Member Application Newsletter Main MotivationMembership Level Organizational ($250/yr) Individual ($150/yr)Who is paying the AAPG membership fee? Organization IndividualPreviousNextPersonal InformationThis section is about information pertaining to you.Position/TitleFirst NameLast NamePrimary PhonePrimary Email (Please double check the spelling!!)Secondary EmailPreviousNextPersonal Information (cont.)This section is a continuation of information pertaining to you.Licenses/CertificationsAddressCityStateZIPPreviousNextOrganizational InformationThis section is about information pertaining to your organization.Organization NameOrganization PhoneOrganization AddressAddress Line 1Address Line 2CityStateZIPWebsiteWhich social media platform(s) does your organization use? Facebook X (formerly Twitter) Instagram YouTube LinkedIn Other We don't use social mediaFacebookX (formerly Twitter)InstagramYouTubeLinkedInOther Social Media AccountsYear Organization EstablishedWhat is your organization's structure? Nonprofit For profitWhat are your organization's funding sources? Private Grants Local Grants State Grants Federal Grants Client/Caregiver Direct Pay Insurance OtherWhich insurance companies?If other, please specify:Is your organization abstinence based? Yes NoTIP: for the below question of 'How many different geographies does your organization serve?': Two weekly meetings where attendance is predominantly DIFFERENT count's as serving two different geographies such as meetings held on the north and south sides of town, held in different cities, etc. Two weekly meetings where attendance is predominantly THE SAME count's as serving only one geography.# of Operational Geographies# of Recoveree Weekly Meetings# of Caregiver Weekly MeetingsPreviousNextOrganizational Information (cont.)This section is a continuation of information pertaining to your organization.Director First NameDirector Last NameDirector's Licenses/CertificationsDirector's Phone Director's EmailDo you want your organization's director's contact information to be publicly posted in the AAPG Member Directory? Yes NoContact Person First NameContact Person Last NameContact Person Phone Contact Person EmailApprox # of Recoverees Served Annually Under 50 50 - 200 201 - 400 >400Approx # of Caregivers Served Annually Under 50 50 - 200 201 - 400 >400Services Offered Adolescent Support Groups Adolescent Family Support Groups 18 and Up Support Groups 18 and Up Family Support Groups Intensive Outpatient Individual Counseling Family Counseling Social Functions OtherIf other service(s) offered, please specify.Newcomer Participation Limits (if any)Requirements for Membership (if any)PreviousNextOrganizational Information (cont.)This section is a continuation of information pertaining to your organization.About your organizationCan the above 'About' paragraph be displayed publicly on the AAPG's Member Directory webpage? Yes NoAbout Your Organization (Public Version)High Resolution Logo Upload (Vectorized Images Preferred)Choose Image Can the uploaded logo be displayed publicly on the AAPG's Member Directory webpage? Yes NoWhat is your/your organzation's vision for how you would like to develop your APG program in the next 1, 3, and 5 years?Additional CommentsPreviousNextMembership PaymentPlease provide your payment details.Name on CardEmailMembership TypeOrganiational$250 for each yearIndividual$150 for each yearNo payment items has been selected yetPay with Card (Stripe) Previous Submit Application
