NGO Application Form

Organization
Organization Name*
Type of Organization*
nonprofit, educational institution, etc.
501c3 Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Staff
CEO Name*
CEO Phone*
CEO Email*
Point of Contact: Name*
Point of Contact: Phone*
Point of Contact: Email*
What year was the organization founded?
Professional Staff Members*
First Name Last Name Role / Position

Please name your staff members and their roles/position. Add or subtract as many rows as you need.
Members of the Board of Directors*
First Name Last Name

Add or subtract as many rows as you need.
Details
Geographic areas of activity.*

Add or subtract as many rows as you need.
Organization Activities*

i.e. mentoring, therapy, drop-in center, education, etc. Add or subtract as many rows as you need.
Target Population*
(who are your services geared towards)
How many individual clients are served annually?*
How many sexual abuse cases were treated in the past year?*
Who is your liability insurance provider?*
Please attach your confidentiality policies

emergency

You know or suspect that a child (under 18) is currently being abused, or is at risk of being abused? act immediately !

If they are in need of emergency care, call 911 or consult with child protective services. You can call anonymously.

Safe Horizons
212-227-3000

RAINN
1-800-656-4673

ACS Office of Advocacy
212-676-9421

SOVRI – 1-888-613-1613

Ohel – 1-800-603-OHEL

Amudim – 646-517-0222

Madraigos – 773-478-6006

First Name	Last Name	Role / Position

First Name	Last Name