Membership Application Membership Information Please fill out the following form, once your membership is approved you will be notified by AFA's Membership Coordinator via e-mail, or phone. Once notified, your annual membership fee will be given to you then. Membership fees are based on the organization's annual operating budget.Membership Type* Member: Open to non profit organizations Associate Member: Open to for profit organizations Please check the following if applicable to your organization Area Agency on Aging/ Government Agency Project Lifesaver International Organization Name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United StatesCanadaAghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Daytime Telephone*Fax NumberWebsite Address Executive Director* Primary Contact* Title* Email* Secondary Contact* Title* Email* I would like my organization to be listed on AFA's website.* Yes No Organization InformationOrganization/Company Category*Nonprofit OrganizationFor-profit Organization/CompanyArea Agency on Aging/Government AgencyProject LifesaverOrganization Type*Adult Day ProgramsAlzheimer's Specific OrganizationAssisted Living FacilityCommunity Health ClinicDoctor's OfficeGovernment OfficeHomecare ProviderHospitalHouse of WorshipLibraryPharmacy or Drug StoreResearch ClinicSenior CenterSupermarket or Convenience StoreOtherServices Provided*Adult Day ProgramsAlzheimer's-Specific ProductsCase ManagementCompanion ServicesConferences/WorkshopsCounselingEducational MaterialsElder LawHot LineLong-term CareMemory ScreeningsNursing ServicesProfessional TrainingResources and ReferralsRespite CareServices/Information in SpanishSupport GroupsYoung-Onset Programs/ServicesOtherGeographical Area Serviced* Number of Employees* Number of Volunteers* Annual Budget ($)* Please provide a short paragraph describing your organization's programs & services.*What are the immediate needs facing your organization?*What are the long-term needs facing your organization?*What additional programs/services would you like to offer in the future?*Please list any additional languages offered.*Please upload your organization's 501C form below Drop files here or Select files Max. file size: 2 MB. CAPTCHA
Membership Application Membership Information Please fill out the following form, once your membership is approved you will be notified by AFA's Membership Coordinator via e-mail, or phone. Once notified, your annual membership fee will be given to you then. Membership fees are based on the organization's annual operating budget.Membership Type* Member: Open to non profit organizations Associate Member: Open to for profit organizations Please check the following if applicable to your organization Area Agency on Aging/ Government Agency Project Lifesaver International Organization Name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code United StatesCanadaAghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Daytime Telephone*Fax NumberWebsite Address Executive Director* Primary Contact* Title* Email* Secondary Contact* Title* Email* I would like my organization to be listed on AFA's website.* Yes No Organization InformationOrganization/Company Category*Nonprofit OrganizationFor-profit Organization/CompanyArea Agency on Aging/Government AgencyProject LifesaverOrganization Type*Adult Day ProgramsAlzheimer's Specific OrganizationAssisted Living FacilityCommunity Health ClinicDoctor's OfficeGovernment OfficeHomecare ProviderHospitalHouse of WorshipLibraryPharmacy or Drug StoreResearch ClinicSenior CenterSupermarket or Convenience StoreOtherServices Provided*Adult Day ProgramsAlzheimer's-Specific ProductsCase ManagementCompanion ServicesConferences/WorkshopsCounselingEducational MaterialsElder LawHot LineLong-term CareMemory ScreeningsNursing ServicesProfessional TrainingResources and ReferralsRespite CareServices/Information in SpanishSupport GroupsYoung-Onset Programs/ServicesOtherGeographical Area Serviced* Number of Employees* Number of Volunteers* Annual Budget ($)* Please provide a short paragraph describing your organization's programs & services.*What are the immediate needs facing your organization?*What are the long-term needs facing your organization?*What additional programs/services would you like to offer in the future?*Please list any additional languages offered.*Please upload your organization's 501C form below Drop files here or Select files Max. file size: 2 MB. CAPTCHA
