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Affiliate Application Form

As a provider of resources, services and/or products that actively promote optimal human development as described in the aTLC Blueprint, I/we agree to:
Grant permission to aTLC to publish our name as an Endorser of aTLC’s Proclamation and Blueprint of Principles and Actions,
Allow publication of our Affiliate information, associated links, and email addresses, on the aTLC website and literature,
Publish introductory information and occasional announcements about aTLC in our literature and on our website.
If you checked all three boxes, please complete the form below.
* = required fields
 ** = fields required only for organizations
Applying as organization or individual? Organization
Individual
**Name of organization
Name of individual applicant or **organization's contact person:
*First name
*Last name & suffix (e.g. advanced degrees, credentials, "Jr.," etc.)
Title
*Email address
(**of contact person)
Website URL
Street or PO Box
City, State/Province, ZIP/Postcode City State/Province
ZIP/Postcode
Country (if not US)
Phone
Fax
What about aTLC inspires you to become an Affiliate?
What specific portion(s) of the Blueprint are most relevant to your work?
Are there any portions of the Blueprint that concern you or about which you would like to offer feedback?
Please provide your mission statement or a brief description of your work (please enter text or a URL to an appropriate page on your site

Survey (optional)

Please rate the value of these Affiliate benefits to you (3=very valuable)

 Mutual support, synergy, and a greater sense of community.

 Promotion of your resources and services to the public through referrals from the aTLC website and literature.

 Being part of a unified voice for bringing principles and actions that support optimal human development into the mainstream.

 The opportunity to utilize and contribute to aTLC’s database of evidence-based research.

 Other (please describe in the ideas and suggestions field below).
Additional ideas and suggestions, including any comments to help us improve this form and the Affiliation process.
*Submitted by