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Membership

YES! I would like to be a member of KCSDV.

I want to become a member of the Kansas Coalition Against Sexual and Domestic Violence (KCSDV) in support of the statewide effort to end violence against the women, men, and children of Kansas.

Contact information:

Name*

Email Address*

Mailing address:

Street*

City*

State* Zip*

Membership type:

Check 1 or more of the checkboxes below.

Ally Organization: $100.00 (Any organization or group of three or more persons whose primary purpose is other than providing services to victims of sexual and/or domestic violence.)

Individual member: $20.00 (Any person who subscribes to the purpose of the Coalition and who pays annual dues.)

KCSDV Member Program Advocate or Survivor: $5.00

KCSDV Member Program name

Payment method: (choose one)

If paying by credit card, please enter the last four digits of the credit card you will be using.

If paying by credit card, you will be directed to the Click & Pledge secure online payment system after submitting this form.

Submit this form

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