2025 Program Membership

2025 Membership Renewal
Executive (or Interim) Director's Name*

First NameLast NameSuffix
Executive (or Interim) Email Address*

Confirmation EmailConfirm Email Address
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 of person completing this document*

Confirmation EmailConfirm Email Address

Type of Service Provider: Please select all that apply*

	Government Agency	Culturally Specific Program	Tribal Specific	Other
Domestic Violence Service Provider
Sexual Assault/Domestic Violence Dual Service Provider
Other victim service provider
Other organizational member

Does your program receive grant funding from the Wisconsin Department of Children & Families (DCF)?*

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

YesNo
Are you a Tribal program?*

YesNo
Do you run a shelter?*

YesNo
If you run a shelter, please provide details about the services you can provide.
What region is your program located in? Select all that apply from this list.

NortheasternNorthernSoutheasternSouthernWestern
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Click here to view the End Domestic Abuse WI Regions Map
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Signature*

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2025 Membership Dues
Select Payment Method:*

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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
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Membership ID
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Training Access Code
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2025 Membership Renewal

Certification

2025 Membership Dues

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