Enter your FIRST name: *

Enter your LAST name: *

Which category describes your role in supporting children and families in North Carolina? * Private Sector Professional Individual Advocate Public or Nonprofit Professional

Enter the full name of the organization or business you work for (please avoid abbreviations): *

Enter the email address where you’d like to receive Alliance communications: *

OPTIONAL, enter an ALTERNATE email address:

Enter your role/title: *

Are you a trainer of (select all that apply): * Protective FactorsConnections MatterCommunity Resilience ModelHOPEDarkness to LightI am not a trainer of any of the above curricula

Are you a facilitator or program supervisor/coordinator of (select all that apply): * Circle of ParentsThe Incredible YearsTriple P Level 4Parents as TeachersStrengthening FamiliesAnother program that is not listedI am not a facilitator or program supervisor/coordinator of a parent support/education program

Are you a member of the NC Family Resource Center Network? * Yes No

Are you a Community Child Protection Team (CCPT) member? * Yes No

Are you a CCPT chairperson? * Yes No

Are you a Parent Leader? * Yes No

Enter your phone number: *

Select the county you live in: * Alamance Alexander Alleghany Anson Ashe Avery Beaufort Bertie Bladen Brunswick Buncombe Burke Cabarrus Caldwell Camden Carteret Caswell Catawba Chatham Cherokee Chowan Clay Cleveland Columbus Craven Cumberland Currituck Dare Davidson Davie Duplin Durham Edgecombe Forsyth Franklin Gaston Gates Graham Granville Greene Guilford Halifax Harnett Haywood Henderson Hertford Hoke Hyde Iredell Jackson Johnston Jones Lee Lenoir Lincoln McDowell Macon Madison Martin Mecklenburg Mitchell Montgomery Moore Nash New Hanover Northampton Onslow Orange Pamlico Pasquotank Pender Perquimans Person Pitt Polk Randolph Richmond Robeson Rockingham Rowan Rutherford Sampson Scotland Stanly Stokes Surry Swain Transylvania Tyrrell Union Vance Wake Warren Washington Watauga Wayne Wilkes Wilson Yadkin Yancey N/A – I am not a NC resident.

Membership Agreement: * I agree to become a member of the Positive Childhood Alliance and to receive updates and communications related to the Alliance's initiatives.

Comments