IAC Membership Interest Form
First Name
Last Name
Title/Role
Email
Phone
Agency Name
Which category best describes your organization or business? Select all that apply. Nonprofit Provider Organization / Human Services AgencyProvider Association or NetworkSchool (P-12)Clinic / Medical ServicesEarly InterventionUniversity or Academic Institute / CenterThink Tank/Research OrganizationHospital or Health SystemPrivate FoundationLabor Union 501(c)5Social Welfare 501(c)4527 PACOther NonprofitFamily Advocacy GroupYouth or Education AdvocacyLearning CommunitySelf-AdvocacyOther Advocacy or Interest GroupGovernment or Public Affairs / LobbyingTraining / Workforce DevelopmentLegalAccounting / FinancialHealthcare / InsuranceOther
Main Office Address
City
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Main Office Phone
Agency Services Provided: Check all that apply. Article 16 ClinicArticle 28 ClinicArticle 31 ClinicCommunity HabilitationRespiteDay HabilitationEarly InterventionFamily CareFamily Support Services (FSS)Individual Residential AlternativeIndividual/Community Support (ISS/CSS)Intermediate Care FacilityApartmentsSelf-Directed Services-Fiscal IntermediarySelf-Directed Services-BrokerSelf-Directed Services-Shared LivingSelf-Directed Services-Paid NeighborEmployment ServicesPrimary Medical ServicesSED 4410 State-Approved Non Public Pre-SchoolSED 853 State-Approved Non Public SchoolSheltered WorkshopSkilled NursingHARP-Health & Recovery Program
Counties in which your agency provides services BronxBrooklyn (Kings)QueensManhattanStaten Island (Richmond)NassauSuffolkWestchesterRocklandPutnamOrangeDutchessCapital RegionCentral New YorkMohawk ValleyFinger LakesNorth CountryWestern New YorkSouthern Tier
How did you hear about IAC? (Website, Social Media, Event, Referral - please specify, Other - please specify) Website Social Media Event Referral Other
Other
What interests you most about IAC's services? Why does your organization want to join IAC?
Consent to Communications Yes No
Comments