Potential Affiliate Interest Form

Potential Affiliate Interest Form

Our goal is to be the most effective mother-centric intervention program in the country to see preventable causes for family separation eradicated. This is only possible through the collaborative impact of local organizations, churches, and advocates. By equipping value-aligned organizations with this program, we will collectively reach more mothers in crisis and strengthen our impact in communities where mothers and children are more vulnerable. Community based organizations are the first line of defense in this work! You are meeting moms at critical points throughout their crisis journey and making a difference in the life of vulnerable families.
Becoming part of our Affiliate Network is more than adding a program to your list of services—it’s joining a deeply rooted partnership. We honor the impact and reputation you’ve cultivated in your community, and in turn provide access to high-quality training, research-based and trauma-informed curriculum, custom case management software, a commitment to continual improvement that expands our shared impact, and a dedicated Affiliate Support team.

Help us get to know you better by filling out the information below!
Name of Person filling out the form

First NameLast Name
Job Title
How many years have you been in your current role?
How would you best describe your role within your organization?

Executive leader - I set strategic direction and sign off on partnership & programmatic decisions.Director level - I direct the day-to-day operations within my department.Management level - I oversee program team members who implement the work.Direct Services - I work directly with clients.
Email address
example@example.com
Phone number
Organization Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization website
How long has the organization been in operation?
How did you hear about ĒMA?

Online- came across website, social media, etcKnew someone helped by ĒMANetworking/Partner group- Praxis, CAFO, Stand Together, etc.Another Affiliate organizationMutual contact introduced usOther
Organization mission statement
Organization vision statement
Organization Core Values
Briefly describe your core programs of service.
Briefly describe the majority of clients you serve.
How do clients hear about your program and/or who are your main referral partners?
Briefly describe your current volunteer opportunities.
What interests you about the ĒMA program and our model of redemptive mother advocacy?
How does your organization understand the foster care crisis, and what part do you believe prevention plays in addressing it?
What role, if any, do you see the church playing in supporting families and preventing foster care involvement?
Is your organization comfortable working with communities of faith on this issue?
I understand that the ĒMA program requires an investment from the Affiliate organization of internal staffing resources to champion and supervise the program, along with a full-time ĒMA Coordinator staff position to implement the program.

Yes, I understand.Yes, but I have more questions.We cannot commit to those requirements at this time but would still like to learn more.
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