Affiliate Partner Interest Form
Name of person filling out the form
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Role Title
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How many years have you been in your current role?
How would you best describe your role within your organization?
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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 Service - I work directly with clients.
Email address
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Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization Name
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How long has the organization been in operation?
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Address
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Street Address Line 2
City
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State / Province
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Postal / Zip Code
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Organization website
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Organization mission statement
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How did you hear about ĒMA?
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Online- came across website, social media, etc
Knew someone helped by ĒMA
Networking/Partner group- Praxis, CAFO, Stand Together, etc.
Another Affiliate organization
Mutual contact introduced us
other
Other
Organization vision statement
Organization Core Values
Briefly describe your core programs of service.
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Briefly describe the majority of clients you serve.
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How do clients hear about your program and/or who are your main referral partners?
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Briefly describe your current volunteer opportunities.
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What interests you about the ĒMA program and our model of redemptive mother advocacy?
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What need or gap could you envision the ĒMA program solving for your organization?
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How does your organization understand the foster care crisis, and what part do you believe prevention plays in addressing it?
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What role, if any, do you see the church playing in supporting families and preventing foster care involvement?
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Is your organization comfortable working with communities of faith on this issue?
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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.
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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.
Submit
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