MEMBERSHIP FORM

MEMBERSHIP APPLICATION FORM
Reconnect Health Development Initiative is a mental health charity that works with individuals, groups and organizations to provide support to people affected by mental illness and drug addiction. Reconnect HDI works to build a web of support across the globe, giving people the opportunity to serve humanity through our organization.

It is important that the name of Reconnect HDI be associated with integrity, ethics, and values that support the public good, that is why we are reaching out to well meaning individuals to join us in this noble cause.

MEMBER EXPECTATIONS / DUTIES
- Attend reconnect HDI meetings.
- Attend workshops, seminars and training as a reconnect member as the need arises.
- Represent Reconnect HDI at events RHDI is invited for.
- Provide relevant services in line with the mission and vision of RHDI for our projects, e.g. nursing care, consultation, psychotherapy sessions/counseling, photography sessions, lectures, public speaking, etc.
- Pay a one off membership fee of 500.
- Annual membership fee of 1000 yearly.
Your membership supports our mission to maximize mental health awareness, to help secure the rights of affected individuals and families and to promote increased access to quality mental health and drug rehabilitation services in order to give hope to families and individuals affected.
MEMBERSHIP FORM

If you would like to be a member, kindly complete the form below.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

City/StateCountry

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: 0000-000-0000.
Email
example@example.com
Highest Qualification
State your area of expertise / specialization
Should your expertise be needed, would you like to volunteer in that area?
Briefly describe how you wish to render your services and/or what activities you wish to be involved in
Availability; select an option

Other

If you are available only part time , what days of the week will you be available?

Rows	AM (8am - 12noon)	PM (12noon - 5pm)
Monday
Tuesday
Wednessday
Thursday
Friday
Saturday
Sunday

If your availability does not fall under any of the above categories , kindly provide details of your availability. ( eg 1hr a week, 2hrs a month)
As an NGO, we thrive from the collective contribution of people like you. Will you like to make a donation to Reconnect HDI?
If Yes, how often would you like to donate?

Other
Amount
How would you like to be contacted ?

Other
Payments should be made to:

Account Holder: Reconnect Health Development Initiative

Bank Name: Zenith Bank

Account Number: 1016809825

(If Western Union is used, please contact us for specific directions prior to sending funds)

Reconnect HDI Membership Policy:

A Reconnect HDI member is allowed to state that they are members of Reconnect Health Development Initiative; however, it may not state that it is an official representative of the Reconnect Health Development Initiative without the permission from the organization. Any use of the Reconnect HDI logo by a member or member organization requires the express permission of the Organization.

Membership is activated only when membership application is approved by the Reconnect HDI Membership Committee.

Declaration:

I declare that all the information furnished in this form is true to the best of my knowledge. I have read the membership policy and I will abide by them and work in the interest of the organization. I acknowledge that membership can be cancelled by the executive committee if my activities or conduct are deemed unfit for the organization. By signing this document, I agree to be a member of Reconnect Health Development Initiative as indicated, to work towards its goals and objectives.
Date

DayMonthYear
Date
Applicant's Name

First NameLast Name
Should be Empty:

MEMBERSHIP APPLICATION FORM

MEMBERSHIP FORM