Prevention Council Re-Chartering Agreement Prevention Council Re-Chartering Agreement This document establishes the agreement between Prevent Child Abuse Indiana, a Division of The Villages, (heretofore referred to as “PCAIN”) and (type Your Council's Name) Name of Council (heretofore referred to as “PCAIN Chartered Council”) for the period of January 1st to December 31st. The Agreement The agreement between PCAIN and all PCAIN Chartered Councils is based on the mutual understanding that we will continually work together to build a statewide organization and network that enables all sectors of the community to play a significant role in preventing child abuse and neglect. Mutuality of Agreement In affirmation of our agreement, both PCAIN and the PCAIN Chartered Council will support and promote one another to the greatest extent possible. It is respectfully understood that each of our activities in some way reflects on Prevent Child Abuse America (PCAA) as well as our state and local images. Each entity must take great care to ensure that our actions correspond with the vision, core values, guiding principles and position statements established by PCAA. PCAIN Responsibilities PCAIN has a commitment to provide technical assistance to Chartered Councils, resources permitting. Chartered Councils will receive all established benefits, outlined in Appendix A. Council Responsibilities Chartered Councils are expected to maintain compliance with the criteria for PCAIN Chartered Councils throughout the charter period (Appendix B). Should there be any major change in a Council’s organization or in its ability to be in compliance with the criteria, the Council agrees to notify PCAIN in writing within sixty (60) calendar days. The Charter This charter acknowledges that the PCAIN Chartered Council is in compliance with the criteria of PCAIN and is granted annually. When a charter is granted, the PCAIN Chartered Council will pay a yearly Chartering Fee. Chartering fees are not refundable. Appendices The Appendices (A through H) are considered an integral part of this Chartering Agreement and can be accessed on the PCAIN Council Portal at www.pcain.org under Council Documents. Certification As an authorized officer of Authorized Officer I hereby certify that our organization is applying to be a Chartered Prevention Council of Prevent Child Abuse Indiana. I further certify that we understand this agreement (including all Appendices) and that we will maintain compliance with it. I agree that our Council’s Officers will review the Appendices yearly. Type Your Full Name President (or Presiding Officer) Today's Date County/Counties Served Primary Contact Information This information will appear on the Prevent Child Abuse Indiana website so that people can contact your Council. It is important that the contact person is available to receive information. We will also use this information to send postal mail. Responsibilities of the Primary Contact Person are: Be available to the PCAIN Staff through email and phone Act as the messenger to the rest of your Council’s Officers and Volunteers Notify PCAIN Staff of any Officer or Contact changes Primary Contact Person Mailing Address Mailing Address Mailing Address Mailing Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Email Preferred Phone Preferred Phone Type Home Work Cell Alternate Phone Alternate Phone Type Home Work Cell Shipping Address Shipping Address Shipping Address Shipping Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Description of Council Activities (to be used on PCAIN website on your council page) * Does your Council operate under the umbrella of another organization and use their 501c3? No Yes Name of that Organization Does your Council have its own 501c3? Yes No Federal Tax Exempt # When do you usually hold your meetings? * (i.e., monthly, bi-monthly, etc.) Day of the week * Monday Tuesday Wednesday Thursday Friday Saturday Sunday Week of the month * First Second Third Fourth Time 121234567891011 : 0030 AMPM Meeting location * Meeting location Meeting location Meeting location City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Anticipated Needs for the coming year * Strategic planning Volunteer recruitment Board orientation No needs at this time Other needs Describe other needs Do you want a free box of prevention brochures? Yes No (100 of each English Brochure – will send to street address indicated above) Prevention Council Officers President President Name * President Term Expires Month & Year President Email * President Preferred Phone * President Preferred Phone Type Home Work Cell President Alternate Phone President Alternate Phone Type Home Work Cell Vice President Vice President Name * Vice President Term Expires Month & Year Vice President Email * Vice President Preferred Phone * Vice President Preferred Phone Type Home Work Cell Secretary Secretary Name * Secretary Term Expires Month & Year Secretary Email * Secretary Preferred Phone Secretary Preferred Phone Type Home Work Cell Treasurer Treasurer Name * Treasurer Term Expires Month & Year Treasurer Email * Treasurer Preferred Phone Treasurer Preferred Phone Type Home Work Cell Please notify PCAIN of any Officer Changes throughout the year Prevention Council Members Please provide the names and contact information for other members of your Council who do not serve as officers. We use this list when sending out the Council Courier Enewsletter. Our lists are not shared with other persons/organizations outside of PCAIN. Depending on the number of members, you may need to duplicate this page. Board Members/Council Volunteers -- Please fill out (emails will only be used to send out Council Courier Newsletter) Name Email Add Remove Each Chartered Council may receive up to two cases of pinwheels at no charge. Each case contains 240 pinwheels, a total of 480 pinwheels. Please determine whether two cases will work for you. How many FREE cases of pinwheels does your Prevention Council wish to order for the upcoming year? * None One Two If you need MORE than two cases, each additional case will cost $110 each. If you need more throughout the year, please order them from our shop. How many additional cases do you need? * $100 each Pinwheel Shipping Information * Pinwheel Shipping Information Pinwheel Shipping Information Pinwheel Shipping Information City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Pinwheel Shipping Phone * Phone Pinwheel Shipping Email * Email How will you pay? Paypal Check (to be sent ASAP to the PCAIN Office) Submit