LSHN Membership Application Form

Fill out and submit the form below to apply as a member. Fields with an asterisk (*) are required.

Organization and Voting Individual Information

Organization Name *

Name(s) of Designated Voting Individual(s) *Organizations can each designate one voting member; you may designate a secondary person as a back-up

Street Address *

City *

State/Province *

ZIP / Postal Code *

Country *

Primary Contact

Name

Email Address *

Phone *

Secondary Contact

Name

Email Address *

Phone *

LHSN Referral Guide Information

The information requested below will be used to create a referral guide that members can use when looking for complimentary or additional services for clients.

Resources *What resources/services does your organization provide? Use individual terms/short phrases, so we can make this searchable. (ie. Housing services, food, employment coaching etc.)

Hours of Operation *

Languages Spoken *Also please indicate if translation services are available on-site.

Transportation *Driving directions and instructions on how to use public transportation to access services. We will be including a map.

Resource Description *Provide a brief description of the resource/service. Please write from a first-person perspective (using I, we or us). Include details on what you offer and how those services or supports can be helpful in meeting a need.

Eligibility *Describe who is able to receive this resource, including any requirements that must be met. Consider immigration status requirements, if applicable.

Referral Needed *Indicate if a formal referral is needed and if it must be given by a specific provider.

How to Access this Service *Describe steps the client must take to access the service (where to go, when, what to ask for, what to expect when there, etc.).

Materials to Bring *Describe what the individual or family must bring to access the service (any required identification, referral documentation, proof of income status, doctor’s note, proof of participation in a related program, etc.). The goal is to avoid multiple visits to access the resource.

Other NotesInclude any other information that would be helpful to the individual or family as they attempt to access the resource.

Membership Dues

Membership dues are based on the size of your Organizational Budget. Please indicate which category your organization falls in by checking the box to the right of your designated payment amount.

Select Your Membership *$100/year - For organizations with budgets LESS than $50,000$200/year - For organizations with budgets between $50,001-$999,000$500/year - For organizations with budgets greater than $1,000,000

Payment Options

Submit this form and make checks payable to Loudoun Human Services Network (LHSN). Please also send your proof of payment to sapna@loudounhumanservicesnetwork.org

If you wish to submit a printed form, you may also download the membership form here:

Download Form

2023 Membership Informational Packet

Download Packet