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?

Please describe the mission of your organization. (This response will be displayed on our website's list of IRF Nation Alliance members.)

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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:

What year was your organization established?

Please select your organization's annual income/revenue range.

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)?

Areas of Work and Support

What are your organization’s main areas of focus? (Please select the top three.)

In which of the following can IRF National Alliance best support your organization? (Please select 5.)

Miscellaneous

How did you hear about the IRF National Alliance? Please select all that apply.

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?

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.

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

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