Application for Membership - Ontario Association of Residences Treating Youth

ABOUT OARTY

MEMBERSHIP

PUBLICATIONS & INFORMATION

PROGRAM & PLACEMENT AVAILABILITY

EVENTS & SPONSORSHIPS

Application for Membership

*

= Mandatory Field

1. Agency Mailing and Membership Information

Agency Name

*

Street Address

*

City

*

Province

*

Country

*

Postal Code

*

Ministry Region

*

Phone

() -

*

Fax

() -

Web Site

Contact Name

		*
(title)	(first name)	(last name)

Position

*

Email Address

Date of First License

*

License Expiry Date

*

For Profit

Yes No

*

Is License

Full Provisional

*

2. References

You only require one reference if your reference is an OARTY member

Reference One:

Agency Name	*	Contact Name	*
Street Address		E-mail Address
City		Province Postal Code
Phone	*	Fax

Reference Two:

Agency Name		Contact Name
Street Address		E-mail Address
City		Province Postal Code
Phone		Fax

3. List three agencies currently using your services

Agency Name		Contact Name
Street Address		E-mail Address
Phone
Fax

Agency Name		Contact Name
Street Address		E-mail Address
Phone
Fax

Agency Name		Contact Name
Street Address		E-mail Address
Phone
Fax

4. Student Field Placements:

Does the agency provide student field placements	Yes No
If you answered yes, please complete the following:
Academic Institution
Total Number of Students per Year

5. Program / Facility Count

How many Programs / Facilities does your agency manage?
(A program / facility is defined as an individual group home residence or a foster care network. A Treatment Foster Program should be counted as one Program / Facility.)

6. Confirmation:

*

authorize OARTY to contact those named above and I confirm that information on this application is correct.
Date: December 1, 2008