PreemieCare Support Sign-up Form

Group Name:

  required

Group Contact Person:

  required

Group E-mail:

  required

Group Phone:

Group Address: 

Group Website:

Group Setting:

Hospital Based   Community Based required

Group Type:

  NICU Support Group Post NICU Support Group NICU & Post NICU Support Preemie Playgroup Bereavement Support Group Early Intervention Parenting Support Group Other required
   ** see below for definitions

Year Established:

  # of Members: 

Paid Membership:

yes   no    If yes, yearly dues: $

Non-profit Status:

yes   no not yet application pending
If Yes, what year:

Group Activities:

Check all that apply

Support Meetings    Online Support Meetings     Playgroups
Professional Education   Presentations/Speakers    Fundraisers
Holiday Parties      Other Events(Reunions)       Other

If other, please describe:   

List any  resources provided by the group to:

Non-members:

New members:

Current members:

Does the group  have an e-newsletter

yes   no  
How can PreemieCare sign up to receive a copy?

Does the group have an online forum, email group, chat feature, or other form of online communication for members?

yes   no  
Please describe:

Tell us about your organizational plans for the future:

PreemieCare Support Group Listing

 Yes, we want our support group listed on the PreemieCare State-by-State/National Support Group Listing

If logo is to be included, provide a link & description of logo:

Provide a short description/mission statement to use on the listing:
 required for listings

Our group is already listed on PreemieCare’s State list
We do not wish to add our group listing at this time

Support Group Leader Discussion Forum

 Yes, I personally want participate on the PreemieCare’s Support Group Leader Discussion Forum

Your name:      required for participants

Your position:   required for participants

Email to use on forum:   required for participants

Preferred username/login:    required for participants

I already participate on PreemieCare’s Discussion Forum
I do not wish to participate at this time