Certified Member Organization Application

You must be regularly offering OMA in order to apply for membership.

*= required field

Today's Date*

Has your organization held OMA sessions in the last 12 months?*

You must be offering OMA regularly to apply for a Certified Member Organization. Please re-apply when you have re-activated your OMA program.

Name*

First Last

Email*

Job Title*

Phone*

Fax

Company Name*

Company Website*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of Residents*

Please enter a number from 1 to 10000.

Not-for-Profit Organization*

Are/Were You a QIP Recipient?*

Name(s) of Trained OMA Facilitator(s) currently employed at your organization:*

Location of OMA Facilitator Training:*

Date of OMA Facilitator Training Completion*

Is This a Certified Organization Membership renewal?*

How often do you conduct the OMA program?*

Which group primarily serves as your volunteers?*

How many pairs of residents and volunteers did you serve in the last 12 months?*

How did you train your OMA volunteers?*

Please click Submit below to complete this form and proceed to payment.