Chapter Registration Form Page 1 Registration Information School Name (no abbreviations) ex: University of California, Los Angeles (not UCLA) I'm ready to register my Active Minds Chapter!I have confirmed that there is not an Active Mind's Chapter at my schoolI have recruited student leaders and a faculty or staff advisor and am ready to provide their contact informationOur chapter has been recognized as a student organization at our school and I am able to provide proof of recognition In this form, you will need to provide the contact information for each chapter leader and advisor, read and sign the Active Minds Chapter Agreement, and provide documentation of your student organization status (pending or registered) from your school. Page 2 Your Contact Information First Name Last Name Email Phone Chapter Information School Street Address City State/ProvincePlease select... AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY NL PE NS NB QC ON MB SK AB BC YT NT NU Other: If "other", Enter State/Province here: Zip/Postal Code Country My school is a...Public SchoolPrivate School Middle School High School or College/UniversityHigh SchoolCollege/UniversityMiddle SchoolOther Is your school a...Community CollegeHistorically Black College or University (HBCU)Hispanic-Serving Institution (HSI)Asian American and Native American Pacific Islander-Serving Institution (AANAPISI)Tribal CollegeOther Minority-Serving InstitutionNone of the aboveGraduate/Professional School Leadership Contact Information Chapters are required to have at least three student leaders, one of whom is not graduating this year, and a faculty or staff advisor. Please provide their contact information.*Note: By joining Active Minds, you join the Active Minds Chapter Network, through which you might receive requests to collaborate, program, or attend events from other Active Minds chapters. We do not share your contact information with people outside of the Chapter Network without your permission. Chapter Leader 1 First Name Last Name Expected Graduation Year Year Leadership PositionPlease select... Chapter President Chapter Leader Chapter Member Email Phone Chapter Leader 2 First Name Last Name Expected Graduation Year Year Leadership PositionPlease select... Chapter President Chapter Leader Chapter Member Email Phone Chapter Leader 3 First Name Last Name Expected Graduation Year Year Leadership PositionPlease select... Chapter President Chapter Leader Chapter Member Email Phone Additional Chapter Leaders First Name Last Name Expected Graduation Year Year Leadership PositionPlease select... Chapter President Chapter Leader Chapter Member Email Phone Primary Advisor Contact Information First Name Last Name Title (e.g. Counselor) Email Phone Additional Advisor Contact First Name Last Name Title (e.g. Counselor) Email Phone Page 3 Chapter Agreement All chapters must read the following chapter agreement and note that they understand and will abide by the rules laid out within. You may print and save a copy for your records here Active Minds Chapter Agreement TextName and BrandingThe chapter will be called “Active Minds at [your school name].” You can use abbreviations or your school nickname in branding or communications with your peers but the formal name of your chapter and in any interactions with the National Office, you should use your full school name.Active Minds maintains several key trademarks including the name of the organization, the tagline (Changing the Conversation Around Mental Health), program titles (Stress Less Week, Send Silence Packing, etc.), and the logos. Chapters are encouraged to use the logo for their own promotional purposes and are required to adhere to the official Active Minds Brand Guide. See more at activeminds.org/logosAffiliationsActive Minds at [your school] is affiliated with Active Minds, the national 501(c)3 nonprofit organization, and is bound by all policies and rules of Active Minds.Active Minds is not financially responsible for Active Minds chapters.Active Minds must be an officially recognized, registered student group at [your school] and abide by all the rules and policies of said educational institution.PurposeActive Minds chapters are established for the expressed purpose of:Increasing the awareness of the students, faculty, and staff at your school about the following:Issues surrounding mental healthSymptoms related to mental health disordersMental health resources available both on campus and in the surrounding communityReducing stigma surrounding mental health disorders so that students will feel more comfortable openly discussing mental-health related issues and seeking help when it is neededSupporting peers to find the skills and resources they need to increase healthy coping techniques that promote personal wellnessProviding a forum and building an open environment for all students to speak up about mental healthMembershipMembership in Active Minds shall be open to anyone who is affiliated with your school in an official capacity (i.e. students, faculty, and staff). All members must welcome anyone affiliated with your school to attend general body meetings of Active Minds.Only active chapter members are eligible to fill officer positions.Active Minds and all affiliates, including Active Minds at [your school], do not discriminate on the basis of race, color, sex, gender identity, gender expression, age, religion, national origin, sexual orientation, source of income, personal appearance, matriculation, political affiliation, marital status, familial status, family responsibilities, mental or physical ability, status as a veteran, or any other legally protected characteristic.There are no dues associated with being a member of Active Minds and chapters are not permitted to mandate dues from their membership so as to not create a barrier to the membership for any individual.OfficersAll elected officers will be currently registered students at your school. The officers should form an executive board.The executive board should be responsible for leading the chapter and ensuring the sustainability of the chapter by understanding Active Minds messages, fulfilling title responsibilities, and representing Active Minds.Officers should be chosen to serve on the executive board from active membership of the chapter through a process outlined by the chapter.The executive board shall consist of at least 3 officers.Additional officer positions can exist on the executive board in order to fulfill additional responsibilities as decided upon by the chapter.If you have any questions about the Chapter Agreement, please contact the Active Minds National Staff: chapters@activeminds.org. I have read and understand the Chapter Agreement and will abide by the rules laid out within. We require all chapters be registered student organizations at their schools. Please attach documentation or email proof of school recognition as an official student group to chapters@activeminds.org. Proof can take the form of a letter or email from a Student Activities or Student Affairs staff member, minutes from a Student Government meeting where they recognize your chapter, or other official documentation.Please select... We are registered with our school and will send an email to chapters@activeminds.org with that documentation. We are working on our school student group registration and will send verification as soon as possible. We will attach documentation below. Attach documentation here. Page 4 Signature Final Step! Please sign this form by typing your name and the date to finalize your chapter registration. Once you hit the submit button it will take up to two weeks to process your registration materials. You will receive an email with your registration status within that timeframe. If you have additional questions in the meantime, please contact chapters@activeminds.org Signature (First and Last Name) Date Please note: The Active Minds National Office usually registers chapters every other week. You will receive an email letting you know about the status of your chapter registration or if we need additional information but please allow at least 14 days for us to process your documentation. reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Contact Information
