Affiliate Application

For the first time in its history, CP State is looking to expand its Affiliate base to include organizations who are leading the way in the provision of services to people with intellectual and developmental disabilities. Our Affiliates hold themselves to operate under the CP values and collective mission of improving the quality of life for people we support and their families.

New Affiliates will include leading organizations in providing innovative programming and supports for people with disabilities, with those organizations focusing their efforts on the future as they build upon our past successes most apt for becoming part of the CP State family.

Read more about the benefits of being a CP State Affiliate:

Organization Name(Required)

CEO Name(Required)

First Last

Address

Street Address Address Line 2 City ZIP Code

Your Email Address(Required)

Email Address Confirm Email Address

Phone

Website

# of Staff

Annual Operating Expenses

Name of Referral Source (if applicable):

Please provide a brief description of your organization/business:

Check the services/information that you are most interested in receiving:

Check all that apply.

Advocacy

Education/Training

Information/Communications Support

OPWDD Support

DOH Support

SED Support

Justice Center/OMIG Support

Other

Your Comments/Questions

Verification

By clicking submit you certify all information is true and correct to the best of your knowledge.