HCA Membership Form 2020-21 (old one)

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Email: hca@humancarealliance.org
Phone: 415.786.2865
PO Box: 7376 | Santa Cruz, CA, 95061
Address: 612 Ocean Street
Santa Cruz, CA, 95061

Email *

MEMBERSHIP *

Renewal

New Membership

Agency Name *

Address (Street, City, Zip) *

Phone # *

Executive Director Name, Email & Phone (New Memberships Only)

Agency Contact | Alternates

Please include all the names and email addresses of individuals you would like to add to the 2019-2020 HCA member email distribution list. These individuals will receive all HCA communication designated for members including meeting agendas, project updates, and members only information. If not applicable, please indicate N/A.

Membership Dues

• Dues are based on operating budgets for Santa Cruz County services only.

• Dues may be paid in 1, 2 or 3 installments.

• Members and potential members may ask for a fee reduction or waiver for cause. No agency will be turned away due to lack of funds. If applicable, please complete the "Dues Reduction" section below.

• Referral discount of 100$

• New members discount of 100$

• Executive members discount of 100$

2020-2021 Budget for Santa Cruz County Programming *

Annual Budget Size & Dues *

Up to $200,000 = $200 Annual Membership Dues

$ 200,001 – $ 500,000 = $500 Annual Membership Dues

$ 500,001 – $ 1,000,000 = $1,000 Annual Membership Dues

$ 1,000,001 – $ 1,500,000 = $1,500 Annual Membership Dues

$ 1,500,001 – $ 2,000,000 = $2,000 Annual Membership Dues

$ 2,000,001 – $ 2,500,000 = $2,500 Annual Membership Dues

$ 2,500,001 – $ 3,000,000 = $3,000 Annual Membership Dues

$ 3,000,001 – $ 3,500,000 = $3,500 Annual Membership Dues

$ 3,500,001 – $ 4,000,000 = $4,000 Annual Membership Dues

$ 4,000,001 – $ 4,500,000 = $4,500 Annual Membership Dues

$ 4,500,001+ = $5,000 Annual Membership Dues

Jurisdictional Funding: Please check all the jurisdictions that fund your agency.

Santa Cruz County

Capitola

City of Santa Cruz

Scotts Valley

Watsonville

Payment Options *

Will mail check. No invoice needed.

Please invoice agency for one payment in full

Please invoice our agency in two installments

Please invoice our agency in three installments

Dues Reduction : If applicable, indicate the proposed dues and a brief description of the basis for your request below.

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