IRF National Alliance Membership Form

IRF National Alliance Membership Form
Completion of this form is a requirement for IRF National Alliance membership and must be completed by an active member of the organization.

If you have questions about this form or IRFNA, please email us at info@irfna.org.
Organization Name
Is your organization a registered charity/nonprofit or a support group?

Support Group (that is not a registered charity/non-profit)Registered Charity/Non-ProfitFor Profit OrganizationIndustry
Please describe the mission of your organization. (This response will be displayed on our website's list of IRF Nation Alliance members.)

0/400
Organization Contacts

Note, these are the two individuals that will receive the IRF National Alliance newsletter and be given seats in the IRF community on the National Alliance Portal. Given this, you may want to include staff members who check their emails regularly and/or have community facing roles.

Your Organization's Primary Contact
Name

First NameLast Name
Job Title
Email
example@example.com
Your Organization's Secondary Contact
Name

First NameLast Name
Job Title
Email
example@example.com
Organization Information
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Official Charity Number/Tax ID
Please check off the locations your organization serves:

LocalStateRegionalNationalGlobal
What year was your organization established?
Please select your organization's annual income/revenue range.

Annual Gross Revenue Less Than $9,999 (USD)Annual Gross Revenue Within $10,000 - $49,999 (USD)Annual Gross Revenue Within $50,000 - $149,999(USD)Annual Gross Revenue Within $150,000 - $299,999 (USD)Annual Gross Revenue Within $300,000 - $499,999 (USD)Annual Gross Revenue Within $500,000 -$999,999 (USD)Annual Gross Revenue Within $1,000,000 - 3 Million (USD)Annual Gross RevenueGreater than 3 Million (USD)
The purpose of this question is to help guide the development of educational tools and resources that are relevant to organizations at different stages in their organizational journey. Information provided in this question may also be used in any future grant review process to holistically evaluate your application.
Social Media Channels

Please input your social media LINKS, not the handles, in the boxes below. For example, input https://www.instagram.com/irfnationalalliance/, not @irfnationalalliance. Please ensure any links entered begin with “https:www.”

This information will be featured on Immune Recovery Foundation’s website along with your organization name and logo. Providing this information will allow visitors to the Immune Recovery Foundation website to easily access information about your organization.
Website Link
Facebook Link
Twitter Link
Instagram Link
Your Organization's Patient Community
What diseases/disease areas does your organization support or represent?
Is your patient organization currently collecting health data from your patients (i.e., registry)?

YesNoUnsure
Areas of Work and Support
What are your organization’s main areas of focus? (Please select the top three.)

Disease EducationAdvocacy/Policy EducationMedical ReferralsMental Health Programs and ServicesCommunity SupportFinancial SupportResearchOther
In which of the following can IRF National Alliance best support your organization? (Please select 5.)

Registry Development and/or ManagementGroup & Community SupportBoard Development Training and Capacity BuildingDiversity, Equity and InclusionResearch ReadinessFundraising/Grant WritingEvent Strategy & OrganizationStarting a non-profitDrug DevelopmentMental Health Content and ProgrammingAdvocacy - Government, Policy & LegislationGeographic/Logistical ExpansionSocial Media StrategyAwareness BuildingWorking with IndustryManaging Staff and Volunteers
Miscellaneous
How did you hear about the IRF National Alliance? Please select all that apply.

Referral from another NA MemberFormer Foundation Alliance MemberFacebook GroupImmune Recovery Foundation WebsiteEventEmailOther
As a IRF National Alliance member, you get access to a National Alliance community within the National Alliance Portal, (once completed), where we share discount codes and networking opportunities for/at upcoming events. Would you like to join the portal?

YesNo
Note, this does not automatically log you into the IRFNA’s Portal. Once completed, you must still complete the steps to log in (i.e. setting a password).
Please upload your organization’s logo. This will be displayed on the IRF National Alliance website. Please ensure your upload is a small PNG or JPEG file.

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If you have questions about this form or the IRF National Alliance please email us at info@irfna.org

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