Missouri Coalition of Recovery Support Providers : Membership : Membership Application

The membership application below can be completed online and will require a number of documents for upload. Please complete the application fully.

2019 MCRSP Membership Application

MCRSP, 221 Metro Drive, Suite B, Jefferson City, MO 65109

Date & Time of Application

Level of Membership (Required)

Choose One

Name of Applicant Organization (Required)

(affiliate, emerging affiliate or single agency name)

Organization Representative #1 (Required)

(Only applicable to affiliate and emerging affiliate applicants)

Email Address (Required)

Organization Representative #1

Organization Representative #2 (Required)

(Only applicable to affiliate and emerging affiliate applicants)

Email Address (Required)

Organization Representative #2

Individual Organization Contact Representative

Individual Organization Contact Email Address

Organization Mailing Address (Required)

(Street Address, no PO Boxes please)

City (Required)

State (Required)

Zip Code (Required)

Business Phone (Required)

Business Fax

Service Area (Required)

(For affiliate and emerging affiliate membership applications please specifically describe the county or counties covered by your organization or otherwise specify the geographic boundaries for the membership you have established.)

For affiliate and emerging affiliate organizations

Number of agency provider members:

(Please give the names and email addresses of separate organizations who are currently a dues-paying member of you affiliate or emerging affiliate organization.)

General Applicant Information

Number of organization employees:

Approximate organization expenditures, latest fiscal year:

Please describe this organization’s significant accomplishments during the past 12 months:

What are this organization’s major planned activities and projects for the next 12 months?

Organization management and governance

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Describe this organization’s governance and leadership structure:

Describe the members’ role in the organization’s governance (For the purpose of this question the term “governance” is in reference to the election of officers, participation on committees, participation at meetings, rights to introduce and to vote on member initiatives, etc):

For affiliate and emerging affiliate applications “member’s role” is in reference to the organizational member’s and for single agency applications the reference is to the individual members of that specific agency.”

Frequency of membership meetings:

Population(s) Served

Choose All That Apply

Adults, Men
Adults, Women
Families
Children & Youth
Veterans/Military
Re-Entry
Not Providing Any Services

Services Provided

In which area(s) will your organizations get involved with the coalition?

Government Relations
Promotions & Events
Membership Support
Education & Training
Sponsorship & Fundraising
Other

Standards, codes of ethics, dispute resolution

Does this organization promote a code of ethics to which all members subscribe, or does it have equivalent ethics provisions in its existing membership requirements?

has formal Code of Ethics
has equivalent
does not have

. Do formal processes exist for membership application and renewal?

Is provider/member status reviewed at least every 2 years?

Describe this organization’s process for resolving complaints from residents and the public about member residences.

Membership and financial records

How are membership records maintained?

Describe your financial record keeping and reporting practices:

How is financial information disseminated to the membership?

Do members have the right to review your organization’s financial records?

Support for MCRSP activities and mission

Is this organization willing to participate in MCRSP activities and programs?

Is this organization willing and able to support MCRSP sponsored research initiatives?

Does this organization intend to conform to MCRSP affiliate or membership requirements?

Does this organization agree to cooperate with MCRSP to resolve complaints MCRSP receives about the affiliate/agency and its respective member?