Arkansas Coalition Against Domestic Violence :: Student Membership Application

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

You will be required to provide proof of enrollment.

1.	Name
	Address
	City
	Zip Code
	County
	School
	Major
	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.