Chapter Affiliation Application

Please complete the following information as part of your request for affiliation as a chapter of The Arc.

Application Type (select one)*
Chapter Type (select one)*
Corporate Information
Legal Business Name*
Federal Tax ID #*
Business Address*
Telephone*
Website URL*
Facebook
Twitter
YouTube
Please list any other business names, or trade names, under which you conduct business.
Please list any other related entities, including but not limited to parent corporations, subsidiary corporations, fundraising or supporting organizations, and property holding companies, regardless of whether nonprofit or for-profit. For each entity, please provide: 1) legal name, 2) business address, 3) website URL if different than the business’ main website, and 4) a short description of the purpose of the entity.
Generally, the corporation listed under “Legal Business Name” in this section and the related entities listed above are considered a single chapter of The Arc. However, in exceptional circumstances, an organization may request that each entity be enrolled as a separate chapter. Would you like to have each entity treated as a separate chapter of The Arc?
If you answered YES, please explain.
Leadership Information
Board President’s Name*
First Last
Board President’s Home Address*
Street Address City State ZIP Code
Board President’s Preferred Telephone*
Board President’s Preferred Email*
Chief Executive’s Name*
First Last
Chief Executive’s Preferred Telephone*
Chief Executive’s Preferred Email*
Qualifying Information
Please provide the following information regarding the corporation listed under “Legal Business Name” in the Corporate Information section above.
Tax Status (select one)*
- The organization has been recognized by the Internal Revenue Service as exempt from taxation under section 501(c)(3) of the Internal Revenue Code.
- The organization has applied to the Internal Revenue Service for recognition as exempt from taxation under section 501(c)(3) of the Internal Revenue Code.
To qualify to be a chapter of The Arc, a nonprofit organization must meaningfully involve people with intellectual and developmental disabilities (IDD) and parents and family members of people with IDD in leading and guiding the organization. There is no single method of meeting this requirement, nor is there a single required governance structure.
Please answer the following about your board. *
Total number of board members*
Number of board members who are parents, siblings, or other family members of persons with IDD*
Number of board members who are self-advocates*
Please answer the following about your management staff. *
Total number of mid-level and senior level management staff*
Number of management staff who are parents, siblings, or other family members of persons with IDD*
Number of management staff who are self-advocates*
Please briefly describe other ways in which people with IDD and their family members are meaningfully involved in leading and guiding your organization.*
Are ALL or SUBSTANTIALLY ALL of the programs, services, and supports provided by your organization delivered in settings that segregate people with IDD from people without disabilities? (select one)*
If you answered YES, please briefly describe the reasons you only provide programs, services, and supports in segregated settings and what, if any, plans you have to move toward an approach to programs, services, and supports that will integrate people with IDD more fully into the larger community.
Membership Category
Fees

As further described in the Standard Terms and Conditions, in order to qualify as a chapter of The Arc, a nonprofit organization must offer individuals the opportunity to be a “member of The Arc” at the national, state, and local levels. A membership that originates at one level of The Arc must be recognized at all levels of The Arc. However, each chapter is free to define categories of membership as it sees fit and to determine what rights, if any, a member may have with respect to their particular organization. Membership may be “voting” or “non-voting.” Members need not play a formal role in the governance of a chapter, although it is permissible if they do so. Please describe in the space provided the current categories of membership that your organization offers, or intends to offer, and the membership fees applicable to each.

Membership Category

Fees

Add up to 3 repeated fields.

Affirmation

The undersigned organization hereby affirms as follows:

a. We have reviewed and understand the content of the following documents which have been provided to us electronically or by link to The Arc’s website:

Bylaws of The Arc of the United States, Inc.
Core Values and Guiding Principles
Position Statements
Federal Public Policy Agenda and Biennial Legislative Agenda

b. We have reviewed our current operations and we pledge to advance, uphold, and strive to conduct our operations in a manner that is consistent with the Core Values and Guiding Principles, Position Statements, and Public Policy Agenda of The Arc.

c. We have reviewed and understand the content of the Standard Terms and Conditions for Affiliation, attached hereto as Exhibit A.

d. We have been provided a copy of the Affiliation Dues Schedule that is currently in effect and understand that dues apply to the calendar year and are due and payable by June 30 of each year unless other payment arrangements have been made. We further understand that The Arc is willing to enter into a payment plan that allows for dues to be paid in monthly or quarterly installments.

e. For organizations applying to be a local chapter of The Arc. *

e. For organizations applying to be a local chapter of The Arc.*

We have obtained the consent from

. The consent was provided by

on*

e. For organizations applying to be a state chapter of The Arc.

We have the support of a majority of the local chapters in

Please complete the following:

Local Chapter Name

Name and Title of Chapter Official

Date Consent Obtained*

f. We have been provided a copy of the Affiliation Dues Schedule that is currently in effect and understand that dues apply to the calendar year and are due and payable by June 30 of each year unless other payment arrangements have been made. We further understand that The Arc is willing to enter into a payment plan that allows for dues to be paid in monthly or quarterly installments.

g. We understand that chapters of The Arc must be prominently identified to the public as an affiliated chapter of The Arc and will do so by the following method (select one).*

We will use the “The Arc” brand identity as our primary business trade name and identity, with geographic or other chapter specific identification.
We will use a business trade name that does not include The Arc’s brand logo but will instead clearly and conspicuously display The Arc’s “affiliated chapter” logo.

The undersigned Organization, identified in the Corporate Information above, hereby certifies that the information contained on this Chapter Affiliation Application is accurate to the best of our knowledge, information, and belief and that the Organization’s Board of Directors has authorized and approved it to become an affiliated chapter of The Arc.

Name of Organization*

Board President/Chairman*

Chief Executive Officer/Executive Director*

Date

Note: You must complete and submit the information on the next page before can begin processing your application.

Policy & Advocacy

Our Initiatives

Get Involved

Get Resources

About Us

Chapter Affiliation Application

Corporate Information

Leadership Information

Qualifying Information

Affirmation