Application for a Local Chapter of KYSAFF

Please print down and complete the application.

1. What is the name of Local Chapter?
   
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2. Please say why you want to be chapter of KYSAFF.
   
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3. Who is the contact person for the local chapter?
   
   

   Name:	_____________________________________________________
   Address:	_____________________________________________________
   Address:	_____________________________________________________
   Phone:	_____________________________________________________
   Email:	_____________________________________________________
   Fax:	_____________________________________________________

4. Will the contact person be the local chapter advisor? Yes / No
   
   
5. If no, who is the advisor?
   
   

   Name:	_____________________________________________________
   Address:	_____________________________________________________
   Address:	_____________________________________________________
   Phone:	_____________________________________________________
   Email:	_____________________________________________________
   Fax:	_____________________________________________________

6. Is there a support agency that will help the local chapter? Yes / No
   
   
7. If yes, what is the mission of support agency?
   
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8. Please provide a statement of commitment about the agency¹s willingness and ability to support self-advocacy.
   
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9. Please provide a statement how the local chapter will regularly communicate and share information with the statewide organization.
   
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Please enclose payment for local chapter dues along with a complete list of your local chapter members.

Application completed by: ________________________________
(Note: the application should be signed by the local chapter self-advocate.)

Please mail this form, the list of chapter members and your chapter dues to:

Cathy Edwards
KYSAFF Secretary
100 Ruth St
Grayson, KY 41143