Escape
SAFETY ALERT: Computer use can be monitored. It is impossible to completely clear the "footprints" showing where each patron has been. If you are in danger, please click the [ESCAPE] bar above to be immediately transferred to another site and return to our site from a safer computer (a computer in a safe location where someone abusive does not have direct or remote access).
ACADV Membership Application home
psa video shelters education about acadv newsletter events workshops members contact
1-800-269-4668 1401 West Capitol Suite 170, Little Rock, AR 72201

If you are in danger:
Call 911
Your local hotline or
U.S. hotline 800-799-SAFE (7233)

Teen Dating Abuse Helpline:
866-331-9474


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Affiliate Membership Application

Programs seeking membership in the Arkansas Coalition Against Domestic Violence (ACADV) must complete the following application. Please answer all questions completely.

1. Name
  Profession
  Address
  City
  Zip Code
  County
  Phone
  Fax
  Email Address
  Please check your preferred method of communication. Phone Fax Email
2. Why are you interested in becoming a member of ACADV?
3. Name of domestic violence program nearest you.
4. Do you have any affiliation with this program? Yes No
  If yes, please describe.
5. You will receive the ACADV newsletter at the above email address unless you check the box to have it mailed to you. Yes, please mail the newsletter to the above address.
PRINCIPLES OF UNITY
 

The members of the Arkansas Coalition Against Domestic Violence recognize that the struggle of each battered woman we serve is related to our individual struggles for personal growth and empowerment. We are committed to the ideas and practices of a supportive, non-competitive atmosphere in all aspects of our programs that fosters open communication, respect and cooperation among all members of the Coalition.

We support and encourage and will work for the participation of all battered women regardless of race, ethnicity, sexual orientation, age, income or physical challenges.

I have read and agree to adhere to the Principles of Unity of the Arkansas Coalition Against Domestic Violence and hereby apply for Supportive Membership on this day of , 20 . Signature:

By submitting this form you are digitally signing the agreement with the name in the box above.

 

 

 


   
 
© Copyright Arkansas Coalition Against Domestic Violence. All Rights Reserved
1401 West Capitol Ave, Suite 170, Little Rock, AR 72201
1-800-269-4668