Become a Member

Membership Application to Veteran Mental Health Leadership Coalition, Inc. (the “Coalition”)

The Veteran Mental Health Leadership Coalition (501(c)(19) advocates for increased research and safe, affordable access to psychedelic medicine and alternative therapies for Veterans and their family members. The Coalition’s members includes (but is not limited to) the leadership of Veteran Service Organizations, Veteran Researchers, Clinicians, Family Members, and other providers both inside and outside the VA healthcare system.

By joining the Coalition, you can play an active role in advancing federal and state policies to usher in the future of mental health care for Veterans.

Types of Membership and Affiliation:
- Member: Membership may be granted to any person who satisfies the qualification requirements outlined below (under Section 501(c)(19) of the Internal Revenue Code of 1986, as amended)** and who is approved in accordance with the bylaws of the Coalition.
  - Individuals who are past or present members of the Armed Forces of the United States.
  - Individuals who are cadets (including students in college or university ROTC programs, or at Armed Services academies).
  - Spouses, widows, widowers, ancestors, or lineal descendants within two degrees of consanguinity of past or present members of the Armed Forces of the United States or of cadets. (i.e., grandparent, brother, sister, grandchild represent the most distant allowable relationships)
- Coalition Advocate: Coalition Advocate status is open to individuals who have actively furthered the Coalition's charitable purposes but who do not qualify or are not approved as a Member. Coalition Advocate status may be granted to any person who completes the application form set forth below and is approved in accordance with the bylaws of the Coalition.
- Coalition Partner Organization: The Coalition may elect to associate with other organizations that share similar goals and purposes. The purpose of creating Coalition Partner Organizations is to permit the Coalition to use such Partner Organization’s name for the purpose of advocacy, marketing, and any other purpose that furthers the charitable goals of the Coalition, with the consent of such organization. Coalition Partner Organization status may be granted to any organization that completes the application form set forth below and is approved in accordance with the bylaws of the Coalition.

Professional Title*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
How did you hear about the Coalition?*

Are you a past or present member of the United States Armed Forces?*
Branch of Service*
Years served (i.e. Active 2002-2006, Reserve 2006-2020)*
List the conflicts you served in if any (i.e. OIF III, OIF 07-09, etc.)*
I affirm, under the penalties of perjury, that the information provided above is true and accurate.*

Yes

Membership Affiliation

Read the different types of memberships and requirements below and select the best option.
- An individual who is joining the coalition will either be a:
  - Member (Military Affiliation)
  - Coalition Advocate (No Military Affiliation - Neither a Cadet or a Relation to a Military Veteran)
- A Founding Member or Coalition Advocate can also apply for their organization to become a Coalition Partner Organization.
- An Organization can apply solely as a Coalition Partner Organization.
  - Select: (Coalition Partner Organization Only)
Membership Type and Requirements

Member Only - I am applying to become a Member of the Coalition to further the work which the Coalition is engaged in. I affirm, under the penalties of perjury, that I:
- Qualify to become a Member of the Coalition as provided in its bylaws;
- Qualify for membership pursuant to Section 501(c)(19) of the Internal Revenue Code; and
- I am an active service member of the United States Armed Forces or that I am a veteran of the Armed Forces of the United States and I provided documentary evidence of such service to the Coalition, if applicable.
Coalition Advocate Only - I do not meet the requirements to become a Founding Member of the Coalition and am applying to become a Coalition Advocate only.

Coalition Partner Organization Only -  I am an authorized representative of the organization I list on the following page, and I hereby represent and warrant that I am authorized to apply for Coalition Partner Organization status for my Organization. Additionally, I am authorized to permit the Coalition to use the name and likeness of my Organization for the purpose of furthering the work of the Coalition, including the attached logo of my Organization.

Member + Coalition Partner Organization - I am applying to become a Member of the Coalition and affirm, under the penalties of perjury, that I meet the requirements for a Member set forth above. Further, I hereby represent and warrant that I am an authorized representative of the organization I list on the following page, and in joining the Coalition, I am authorized to apply for Coalition Partner Organization status for my Organization. Additionally, I am authorized to permit the Coalition to use the name and likeness of my Organization for the purpose of furthering the work of the Coalition, including the attached logo of my Organization.

Coalition Advocate + Coalition Partner Organization - I do not meet the requirements to become a Founding Member of the Coalition and am applying to become a Coalition Advocate and Coalition Partner Organization. I hereby represent and warrant that I am an authorized representative of the organization I list on the following page, and in joining the Coalition, I am authorized to apply for Coalition Partner Organization status for my Organization. Additionally, I am authorized to permit the Coalition to use the name and likeness of my Organization for the purpose of furthering the work of the Coalition, including the attached logo of my Organization.
Please select your Membership*

I affirm that the information submitted is true, correct, and voluntarily given. I hereby grant permission to the Coalition to review my application and documentation for inclusion as a Member of the Coalition. Your e-signature will be used to represent you on official VMHLC document submissions.*

Yes
Date*
Digital Signature*

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I authorize and consent to the Coalition's use of my signature for the purpose of furthering the work of the Coalition.*

Yes, I authorize and consentNo, I do not authorize and consent
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