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THE HUT Membership Application
Application for membership to the NAMI Piedmont Tri-County and The HUT/Drop-In Center
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* Indicates required question
Email
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Your email
727-433-3937
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Your answer
Julia Jones
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Your answer
Date of Application
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MM
/
DD
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YYYY
Membership in NAMI Piedmont Tri-County is a requirement to attend some programs and classes (NOT ALL) at The HUT. Membership is as low as $5 a year. ALL MEMBERS MUST COMPLETE THIS FORM for Emergency Purposes.
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Do you have a current membership?
Has your membership expired and you would like to renew membership?
I wish to become a member (As low as $5 a year) register here:
https://tinyurl.com/2bmj3tfz
I just wish to attend events at The HUT not be a drop-in member at this time.
Other:
Required
Do you live with a mental illness or are you a caregiver, family member or friend of someone who lives with a mental illness?
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Yes, I live with a mental illness
Yes, family member, caregiver and friend of someone who lives with a mental illness.
I am a case manager, therapist or other professional and would like to volunteer my expertise at the center.
I would like to volunteer because I want to be part of making my community a better place
Other:
Do you have a medical condition we need to know about? Anaphylaxis, seizure disorder, etc.? Confidential Information only to be used in the purpose of an emergency situation or need. Please type N/A if this does not apply to you.
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Your answer
Emergency Contact, name and phone number
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Your answer
Emergency contact number entered above
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Yes
No - your application will be rejected, please ensure we have an emergency number on file.
Required
By submitting this application you are agreeing to become a member of NAMI Piedmont Tri-County's Drop In Center at The Hut and all that entails. You agree to behave respectfully and with kindness and understanding to those who are also members of the NAMI Piedmont Tri-County Drop In Center. Any violence or crude/repetitive disrespectful language will result in suspension of privilege's at the Center. All applications will be digital and stored on the employees computer. We endeavor to maintain a secure digital environment but offer no liability or promise of privacy in the event of a breach. Please type you agree and understand the limitations of membership.
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Your answer
A copy of your responses will be emailed to the address you provided.
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