Fayette County Military Suicide Prevention Coalition Membership Application
Thank you for your interest in becoming a member of the Fayette County Military Suicide Prevention Coalition (FCMSPC). Please complete the form below to apply for membership.
Personal Information:
Full Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
example@example.com
Preferred Contact Method (Phone (Text)/Email):
Please Attach a Recent Professional Head shot below (JPEG or PNG format)
Back
Next
Employment & Military Affiliation
Current Place of Employment (if applicable):
Military Affiliation: (Check all that apply):
Active Duty
Retired
Disabled Veteran (Service Connected)
Veteran
Non-Veteran
Military Spouse
Branch of Service (If Applicable):
Army
Air Force
Navy
Marines
Coast Guard
Space Force
Army National Guard
Reservist
Dates of Service (If Applicable):
War Conflicts (If Applicable):
Back
Next
Community Engagement & Organizational Involvement
Referred By:
Community Affiliations & Other Memberships:
Positions Held in Other Organizations:
What have you done in the community to support or raise awareness on military-related topics or issues?
Back
Next
Special Skills and Expertise: (Please list any special skills that could benefit the coalition, such as event planning, fundraising, public speaking, mental health training, etc.)
Why Do You Want to Join FCMSPC?: (Explain your motivation for joining and how you hope to contribute.)
Are you interested in becoming a Board of Directorate member (full-time)?
Yes
No
Are you interested in becoming a Coalition Officer (full-time)?
Yes
No
Upload Resume (if applying for Board or Officer Member position):
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Membership Type:
General Voting Member ($15-$25) Donation
General Member (Non-Voting)
Part-Time Member (limited participation)
Event Volunteer Only
FCMSPC Mission Statement:
The Fayette County Military Suicide Prevention Coalition (FCMSPC) is dedicated to preventing military and veteran suicide through advocacy, education, outreach, and community collaboration. Our mission is to create a supportive environment where military members, veterans, and their families feel valued, connected, and empowered.
FCMSPC Commitment Agreement:
By signing this application, I agree to abide by the principles, policies, and bylaws of the Fayette County Military Suicide Prevention Coalition. To the utmost of my abilities, I will assist in creating a community where every military member, veteran, and their families feel valued, connected, and empowered to combat suicide.
Signature
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: