AHDA Institutional Membership Application Form

Thank you for your interest in joining the Alliance for Headache Disorders Advocacy. We ask that you complete the following form. This will be reviewed with our Board at our next quarterly board meeting and we will follow up with you regarding any additional questions and/or next steps. All AHDA members are expected to participate in quarterly Board meetings, serve on a Board Committee, pay membership dues of $1000 per fiscal year and make a meaningful additional contribution based on organization budget.

Please direct all membership related questions to Julienne at director@headachealliance.org.

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Contact Information

First Name Last Name

Pronouns (Optional)

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Employer Information

Occupation Employer

I am retired

Work Address Line 1

Work Postal Code Work City Work State

Work Phone

Additional Information

Does your organization have a board of directors, and if so, who is on your board?

What is your IRS status? (501c3, etc)

Where does your organization get its funding?

Please provide links to your organization's website and social media profiles

Why does your organization want to become a member of AHDA?

What is the mission of your organization and how does AHDA's mission fit into that mission/goals? (Optional)

Are you able to donate the required $1000 annual membership dues?

Yes No

Are you able to contribute additional monies in support of AHDA's mission?

Yes No Maybe

Are you or someone from your organization able to attend at least quarterly Board Meetings and participate in at least one Committee which meets every month?

Yes No

Each Board Member is expected to serve on at least one Committee. Our current Committees are Policy/Communications, Membership/Fundraising and an Ad Hoc Committee on possible 501c3 incorporation. What Committee are you interested in serving on? Why?

Do you have any skillsets you can bring to our board (e.g. financial, legal, research and planning, leadership, etc...). Please specify.

Has your organization participated in legislative advocacy before? If yes, please describe

Is there anything else you would like to share about your organization? (Optional)