Page | 1 of 8 Official Affiliation Form for NEW groups seeking initial Affiliation with NAMI as of April 13, 2020 Application Form for Obtaining Initial NAMI Affiliate Status Process for Endorsement by the NAMI State Organization 1. The group seeking initial affiliation with NAMI submits this application with the required information and documentation to the NAMI State Organization for endorsement. The NAMI State Organization reviews the application and documentation to determine that the applicant group meets the following criteria: a. A name consistent with the NAMI naming policy. “The name of each Affiliate shall begin with “NAMI” followed by a geographic designation of the Affiliate’s local vicinity (e.g., NAMI Anywheretown, NAMI Anywherecity, or NAMI Anywherecounty).” b. The stated mission is consistent with the NAMI mission. “NAMI provides advocacy, education, support and public awareness so that all individuals and families affected by mental illness can build better lives.” c. Meets the feasibility for a new affiliate in the geographic region and determines their intention to meet identified needs in the community. d. Understands the Standards of Excellence and is familiar with the NAMI State Organization’s Model B Affiliate Handbook. (Understands that it will begin to operate as a Model B Affiliate that is unincorporated without bylaws and without a board of directors as a program/division operating under the NAMI State Organization and all its governing policies and procedures.) e. Meets the required initial minimum membership of five. f. Submitted a year-long Affiliate growth plan and has two trained teachers or facilitators to deliver at least one of the NAMI education programs or support groups. g. The application is signed by the applicant group’s chair of the steering committee. 2. The NAMI State Organization’s Board of Directors endorses the application during its board meeting and documents the action in their board meeting minutes. The board president signs the application where indicated. 3. The NAMI State Organization uploads the application and all required documentation to the “Organizational Documents” folder in NAMI 360, named “New Affiliate Formation Guiding Documents for NSO,” subfolder “New Affiliate Documents for review,” and informs NAMI that documents are awaiting national office review via: newaffiliate@nami.org. 4. NAMI reviews the application and raises any relevant questions to the endorsing NAMI State Organization. If approved, NAMI sends a Welcome Letter with next steps for official affiliation with NAMI to the applicant group with a copy to the NAMI State Organization within 28 business days. The chart below offers a short overview of both the benefits and responsibilities of being a NAMI Affiliate. Benefits Responsibilities Visible participation in a well-known national movement that makes a difference in the lives of millions every year; Operate in accordance with laws and statutes that govern your jurisdiction (e.g. city, county, state). Membership in a national network that allows you to tap into expertise on local, state, and federal issues related to mental illness; Collaborate with your NAMI State Organization and NAMI to embrace and conduct business in accordance with the vision, values, and all governing policies and practices of the NAMI State Organization and NAMI. Support and assistance from your NAMI State Organization and NAMI in developing leadership, expanding the reach in your community, and organizing your advocacy efforts. Seek to establish and grow NAMI’s presence in your community.
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Official Affiliation Form for NEW groups seeking initial Affiliation with NAMI as of April 13, 2020
Application Form for Obtaining Initial NAMI Affiliate Status Process for Endorsement by the NAMI State Organization
1. The group seeking initial affiliation with NAMI submits this application with the required information and documentation to the NAMI State Organization for endorsement. The NAMI State Organization reviews the application and documentation to determine that the applicant group meets the following criteria:
a. A name consistent with the NAMI naming policy. “The name of each Affiliate shall begin with “NAMI” followed by a geographic designation of the Affiliate’s local vicinity (e.g., NAMI Anywheretown, NAMI Anywherecity, or NAMI Anywherecounty).”
b. The stated mission is consistent with the NAMI mission. “NAMI provides advocacy, education, support and public awareness so that all individuals and families affected by mental illness can build better lives.”
c. Meets the feasibility for a new affiliate in the geographic region and determines their intention to meet identified needs in the community.
d. Understands the Standards of Excellence and is familiar with the NAMI State Organization’s Model B Affiliate Handbook. (Understands that it will begin to operate as a Model B Affiliate that is unincorporated without bylaws and without a board of directors as a program/division operating under the NAMI State Organization and all its governing policies and procedures.)
e. Meets the required initial minimum membership of five. f. Submitted a year-long Affiliate growth plan and has two trained teachers or facilitators to deliver at
least one of the NAMI education programs or support groups.
g. The application is signed by the applicant group’s chair of the steering committee. 2. The NAMI State Organization’s Board of Directors endorses the application during its board meeting and
documents the action in their board meeting minutes. The board president signs the application where indicated.
3. The NAMI State Organization uploads the application and all required documentation to the “Organizational Documents” folder in NAMI 360, named “New Affiliate Formation Guiding Documents for NSO,” subfolder “New Affiliate Documents for review,” and informs NAMI that documents are awaiting national office review via: [email protected].
4. NAMI reviews the application and raises any relevant questions to the endorsing NAMI State Organization. If approved, NAMI sends a Welcome Letter with next steps for official affiliation with NAMI to the applicant group with a copy to the NAMI State Organization within 28 business days.
The chart below offers a short overview of both the benefits and responsibilities of being a NAMI Affiliate. Benefits Responsibilities Visible participation in a well-known national movement that makes a difference in the lives of millions every year;
Operate in accordance with laws and statutes that govern your jurisdiction (e.g. city, county, state).
Membership in a national network that allows you to tap into expertise on local, state, and federal issues related to mental illness;
Collaborate with your NAMI State Organization and NAMI to embrace and conduct business in accordance with the vision, values, and all governing policies and practices of the NAMI State Organization and NAMI.
Support and assistance from your NAMI State Organization and NAMI in developing leadership, expanding the reach in your community, and organizing your advocacy efforts.
Seek to establish and grow NAMI’s presence in your community.
Official Affiliation Form for NEW groups seeking initial Affiliation with NAMI as of April 13, 2020
Application Form for Obtaining Initial NAMI Affiliate Status
Note: to be completed by the proposed NAMI Affiliate, signed by the NAMI State Organization * required fields
1. * Name of Proposed Affiliate: NAMI Lebanon
2. * Affiliate Address: 26152 Highway 5, Lebanon, MO 65536
3. * Telephone: 417-718-1616 4. * Email: [email protected] Please provide Contact Information for the Newly Formed Affiliate that can be shared on our public website and
for NAMI to be able to conduct business with this Affiliate. 5. * Name of the applicant group’s Steering Committee Chair: Donna Caffey
6. * Name of the applicant group’s Advocacy Representative: John McGinnis 7. * Statement of Purpose (consistent with the NAMI mission statement):
The mission of NAMI Lebanon is to improve the quality of life and recovery for children and adults with mental illness and their families. We accomplish this through support, education, and advocacy.
8. * (Affiliate’s name) NAMI Lebanon Agreed to operate as model B under: (add the NSO’s name in the cell to the right)
NAMI Missouri
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Official Affiliation Form for NEW groups seeking initial Affiliation with NAMI as of April 13, 2020
Application Form for Obtaining Initial NAMI Affiliate Status Please provide below the Applicant’s group membership roster Member’s Name Membership
ID # if known Address, Email, and Phone What is the name of the
Affiliate that NAMI needs to transfer their membership from
1 Donna Caffey 26152 Hwy 5, Lebanon, MO 65536 417-718-1616 [email protected]
NAMI Southwest Missouri
2 Shannon Williams 122 Maple Dr, Lebanon, MO 65536 417-522-2042 [email protected]
NAMI Southwest Missouri
3 John McGinnis
421 S Adams St, Apt 6, Lebanon, MO 65536 417-322-5854 [email protected]
NAMI Southwest Missouri
4 Gayle Hall 19376 Hazel Rd, Lebanon, MO 65536 417-718-5921 [email protected]
NAMI Southwest Missouri
5 Janelle Weaver
23826 Green Hills Rd, Lebanon, MO 65536 417-718-3525 [email protected]
NAMI Southwest Missouri
6 Cody Taylor
1045 Saint Louis St, Lebanon, MO 65536 417-839-2922 [email protected]
Application Form for Obtaining Initial NAMI Affiliate Status
Proposed Plan for Growth and Development of This Affiliate: *According to the NAMI bylaws, the roles and responsibilities of an affiliate include reporting on local issues and needs to NAMI and the NAMI State Organization, and the following activities. Please check the items below that your affiliate is planning to accomplish during its first year:
Official Affiliation Form for NEW groups seeking initial Affiliation with NAMI as of April 13, 2020
Examples of Activities Please name the specific program, support, or other planned for activity
provide NAMI support group(s) 1.) NAMI Family Support Group - NAMI Lebanon hosts a NAMI Family Support Group Meeting every other week on the second and fourth Wednesdays of the month.
2nd & 4th Wednesdays of each month @ 5:30 pm Lebanon Laclede Public Library 915 S. Jefferson Ave., Lebanon Call: 417-718-5921 Email: [email protected]
2.) NAMI Connection Recovery Support Group - NAMI Lebanon
hosts a NAMI Connection Recovery Support Group weekly on Wednesdays.
Weekly – Wednesdays @ 5:30 pm Lebanon Laclede Public Library 915 S. Jefferson Ave., Lebanon Contact: Shannon, 573-552-2042 Email: [email protected]
provide NAMI education programs in the community
3) NAMI Basics – NAMI Lebanon has held a NAMI Basics family education program, which consists weekly 2 ½ hour classes for 6 weeks. The next class date is TBD.
provide local information and referral services
We currently do this.
provide local outreach through community newspapers and bulletins
We currently do this.
interact with local professionals We currently do this. involve other community groups in the NAMI agenda
We currently do this.
work with the local media on matters relating to mental health
We currently do this.
engage with NSO on fundraising activities We plan to remain in regular contact with NAMI Missouri Executive Director Gena Terlizzi and Director of Operations Dawn Matthews on these matters.
engage with NSO on grassroots advocacy on local, state, and federal issues
We are in regular contact with NAMI Missouri Executive Director Gena Terlizzi and Director of Operations Dawn Matthews on these matters.
provide regular activities reports to NSO We are in regular contact with NAMI Missouri Executive Director Gena Terlizzi and Director of Operations Dawn Matthews.
Other (please list):
NAMI Lebanon other programs list NAMI Focus on the Positive – NAMI Lebanon hosts Focus on the Positive Support Group Meeting weekly on Wednesdays. This group is open to those affected with mental illness as well as their loved ones.
Official Affiliation Form for NEW groups seeking initial Affiliation with NAMI as of April 13, 2020
Weekly – Wednesdays @ 10:00 am Lebanon Laclede Public Library 915 S. Jefferson Ave., Lebanon Contact: Donna, 417-718-1616 Email: [email protected] NAMI Splinters in our Souls – NAMI Lebanon will be starting a new Support Group Meeting on Sundays in spring of 2020. This group will invite members to incorporate their spiritual beliefs into their recovery – ‘turning pain into power’. Weekly – Sunday evenings @ TBD Lane Change Addiction Recovery Office 679 West Elm Street, #9, Lebanon Contact: Donna, 417-718-1616 Email: [email protected]
* Seek approval from NSO on the proposed activities for the New Affiliate
Application Form for Obtaining Initial NAMI Affiliate Status *In the space provided below, please write the Affiliate’s initial plan for meeting NAMI’s mission in your community: We will continue to have a presence in print and radio media to increase public awareness and education regarding mental illness. We also participate in activities to enhance not our members but our community, such as our adopt-a-street commission. We provide weekly support groups to those affected by mental illness and their family members. We have developed a contact list for anyone to contact due to crisis or simply isolation due to COVID-19 or other circumstances. We provide outreach to local professional and social organizations – such as speaking at luncheons and participating in community events. Regularly professionals from the community are invited to share their expertise in our support groups. Guests include those with information specifically relevant to many with mental illness such as a local psychiatrist and judge; as well as those who may individually enhance the lives of our members, such as a horticulturist and therapy dog trainer.
Official Affiliation Form for NEW groups seeking initial Affiliation with NAMI as of April 13, 2020
Application Form for Obtaining Initial NAMI Affiliate Status
* Endorsement by NAMI State Organization:
The board of directors of NAMI Missouri has approved the following geographic territory as the current service area for NAMI Lebanon
At a duly convened Board meeting with a quorum present held on June 6, 2020 (date) The Board of Directors of: NAMI Missouri endorses this application for initial affiliate status.
June 6, 2020
(Signature of chair of NAMI State Organization) (date)
