Group Membership Form

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The following questions are for internal purposes only and will not be shared publicly.

Information shared below will be included in the searchable Member Directory on the NICU Parent Network website.

From time to time issues, policies, and updates arise that require a membership vote. There should be ONE voting contact from your Organization/Company and it should be either the CEO, Executive Director, Founder or President

We require TWO references for each Organization/Company application. One may be personal and one should be professional. They may not include one of your board members, staff members, or family members. References should be able to speak to your impact as a leader.

Your Organization/Company will have up to 6 submembers. These submembers will be able to access all the benefits of membership and NPN communications.

Include a submember in your membership registration

Support Org <$50K

Support Org $50K - $149,999 Annual Budget

Support Org $150K - $349K

$350K - $499K Annual Budget

$500K

Professional Affiliate

I would like to automatically renew my membership

Secure Payment

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First Name *

Last Name *

Select here for the GROUP Membership for your Organization/Company

Job Title *

Organization/Company Name *

Email *

Share an email address that can be added to the Member Directory

Website *

Address Line 1 *

This should be the mailing address for the Organization/Company

Address Line 2

City *

Territory

State/Province

Zip/Postal Code *

Country *

Secure Payment

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Are you the parent of a NICU baby? *

yes

Are you the parent of a full-term infant admitted to the NICU?

yes

Are you a bereaved parent?

miscarriage

stillbirth

neonatal loss

infant loss

child loss (18 yrs old or younger)

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Do you have a part-time or full-time job in addition to your Organization/Company? *

Prior to your work in NICU parent support, tell us a little bit about your professional background *

What unique qualities, abilities, knowledge, strengths, etc can your organization bring to the NICU Parent Network? *

What does your organization hope to gain by being a part of the NICU Parent Network? *

Share an experience you personally or your organization has had working with other organizations. *

How did you hear about NICU Parent Network? *

What is your number 1 reason for joining? *

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Voting Contact Name *

Job Title *

Only enter an email if the voting contact is someone other than the main contact for your membership

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Reference #1 Full name *

Relationship *

Email *

Reference #2 Full Name *

Relationship *

Email *

Data Privacy & Consent

Yes, I would like to receive communications from NICU Parent Network by email.

Yes, I would like to receive communications from NICU Parent Network by phone.

Yes, I would like to receive communications from NICU Parent Network by mail.

Yes, I would like to receive text messages from NICU Parent Network.

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Include a submember

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Choose Existing Contact(s)

Membership Level *

I would like to automatically renew my membership

First Name *

Last Name *

Job Title *

Email *

Address Line 1 *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Country *

Add {{subMemberDisplayName}}

Secure Payment

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Discount Code

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Order summary

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Secure Payment

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Card

or enter your card details below

Cardholder First Name *

Cardholder Last Name *

Cardholder Email

Card *

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Billing address is the same as mailing address

Address Line 1

Address Line 2

City