NCIMHA Membership Scholarship Request

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Equity, diversity, inclusion, and access are important to NCIMHA as an organization. As such, we are able to offer full or partial scholarships for annual membership. Please complete the form below and a NCIMHA will representative will be in touch with you shortly regarding the available scholarship options.

Email *

Name *

Position/Role: *

Agency *

I have approached my employer about paying for my NCIMHA annual membership, but they are unwilling/unable to pay because:

I am not currently employed by an agency

My agency is unable to pay membership dues

My agency is unfamiliar with NCIMHA and the membership benefits

Other:

Clear selection

Hourly Wage Rage or Annual Salary (select one):

Less than $15/hour

$15-$25/hour

$25-$35/hour

$35+/hour

Less than $30,000 annually

$30,000-$50,000 annually

$50,000-$75,000 annually

$75,000 or more annually

Other:

Clear selection

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of North Carolina Infant and Early Childhood Mental Health Association. Report Abuse

Forms