2024 Program Membership

2024 Membership Renewal
Executive (or Interim) Director's Name*

First NameLast NameSuffix
Organization’s Legal Name*
Org/Agency Address*

Street Address

Street Address Line 2

CityState

Zip Code
* The Address will be displayed on the End Domestic Abuse Wisconsin website.
Main Office Telephone Number*
Please enter a valid phone number.
Hotline or Main Crisis Telephone Number*
This telephone number will be displayed on the End Domestic Abuse Wisconsin website.
Org/Agency Website Address**
www.yourwebsite.org
Email Address*

Confirmation EmailConfirm Email Address
Will your program receive grant funding from the Wisconsin Department of Children & Families (DCF) in 2024?*

YesNo
Will your program receive grant funding from the Wisconsin Department of Justice Office of Crime Victim Services (OCVS) in 2024?*

YesNo
Are you a Tribal program?*

YesNo
What region is your program located in? Select all that apply from this list.

NortheasternNorthernSoutheasternSouthernWestern
View Regions Map

Click here to view the End Domestic Abuse WI Regions Map
Certification
Click here to view our Mission, Vision, and Values.
Signature*

Clear
2024 Membership Dues
Select Payment Method:*

CheckPayPal (including credit cards)
Membership Dues:*

Annual Budget = $ 0 - $ 50,000 $ 75.00Annual Budget = $50,001 - $75,000 $125.00Annual Budget = $ 75,001 - $150,000 $225.00Annual Budget = $ 150,001 - $300,000 $375.00Annual Budget = $ 300,001 - $600,000 $475.00Annual Budget = $ 600,001 - $800,000 $575.00Annual Budget = $ 800,001 + $700.00
Outreach Offices - $75 for each outreach office your agency has. If you are state-wide agency, please select one County.
Select Total Number of Outreach Offices
Membership Dues
Total Outreach Fees
Total Due
Membership Dues:
prevnext( X )
Annual budget = $ 0 - $ 50,000
$75



Annual Budget = $ $50,001- $ 75,000
$125



Annual Budget = $ 75,001 - $ 150,000
$225



Annual Budget = $ 150,001 - $ 300,000
$375



Annual Budget = $ 300,001 - $ 600,000
$475



Annual Budget = $ 600,001 - $ 800,000
$575



Annual Budget = $800,001 +
$700



Outreach Offices$75 for each outreach office your agency has. If you are state-wide, please select one office.
$75 Number of Outreach Offices



Total

$0.00
loading smart payment buttons...

The payment is ready! It will be completed once you submit the form.
Please click the Submit button to complete registration!
Invoice Paid?
Response
Invoice is paid response
Response 2
Invoice is not paid response
Membership ID
default code to be copied to Training Access ID once paid
Training Access Code
Should be Empty:

2024 Membership Renewal

Certification

2024 Membership Dues

Please click the Submit button to complete registration!