Members Registration

NNED Member Registration Form

The NNED invites organizations and agencies addressing mental health or substance use disparities, with a strong focus on diverse communities, to join the NNED as a Partner. Please complete this registration form to indicate your interest. Please Contact us if you need assistance.

A. Personal Info

First Name

Last Name

Your Title

User Name (choose words without
space characters; email address can
also be used)

Screen Name (can be your name or an alias)

Your Direct Phone Number

Your Degree

B. Purpose for Registration

Select:
  Select
  My organization would like to become a NNED partner
  My organization is currently a NNED partner, and I'd like to sign up as an individual NNED affiliate
  I would like to become a NNED affiliate (individual membership)

C. About Your Organization/Agency

(note: if you are signing up for individual membership and are not currently working under an agency or organization, please skip this section and continue to Section D below.)

Name of Your organization

Department or Division (if applicable)

Organization's Address

City

State

Zip Code

Agency's Phone Number (xxx xxx-xxxx)

Agency's Web Site URL

D. Create a Password

Password

Re-type Password

How did you first hear about the NNED?

For security purpose, please type the test word you see below:

Enter test word →

By submitting this form, you agree to accept the NNED's guiding principles as stated on the NNED website.

Thank you very much for your interest in the NNED! After completion and submission of this form, you will receive an email with additional information to complete the application process. Access to secured areas of NNED web site will be granted after application approval.

The NNED is supported by the Substance Abuse and Mental Health Services Administration, National Institutes of Health/National Institute on Minority Health and Health Disparities, and the Annie E. Casey Foundation

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