Chapter Application for The National Foundation for the Treatment of Pain

Local Chapter Application

1. We have received numerous inquiries about forming local chapters of the Foundation.

2. The Foundation is completely receptive to the formation of local chapters. We believe that local action is very important to successfully accomplishing policy change in pain management. Ideally, every local chapter would have a membership composed of every pain patient and ever doctor who treats pain patients. Also, ideally, every chapter would have a telephone committee which could rapidly call upon the entire membership for intervention and action. Similarly, ideally, every member and every local chapter would have an Email address and be available on-line.

3. The National Foundation must still require national membership for all members, for obvious reasons. In cases of financial hardship, the membership fee can be waived or paid in installments.

4. Also, obviously, we must have a written understanding that no local chapter will initiate any local action, or distribute any policy statement of policy announcement, without clearing it through the National Foundation. Our credibility is priceless and cannot be placed at risk by hasty or injudicious actions.

5. Lastly, also ideally, we want to construct a pain patient database, which will include every single member's profile and history. We do not intend to publicly publish last names, however. We want to construct a data base that is unarguable as to the serious and extent of the suffering people face.

You may submit this application online or print it out and fax it to NFTP 916-726-5517.
After submitting you will receive an authorizing letter.

Date:

1. Location and proposed name of Chapter:

2. Mailing Address:

Street:

City:

State:

Zip:

Phone:

Fax:

E-mail:

3. Proposed local President:

(fill in below if different from above)

Address:

City:

State:

Zip:

Phone:

Fax:

E-mail:

4. Initial membership:

Name:

Address:

City:

State:

Phone:

E-mail:

Diagnosis:
(optional)

Initial membership: (Second Person)

Name:

Address:

City:

State:

Phone:

E-mail:

Diagnosis:
(optional)

Initial membership: (Third Person)

Name:

Address:

City:

State:

Phone:

E-mail:

Diagnosis:
(optional)

Initial membership: (Fourth Person)

Name:

Address:

City:

State:

Phone:

E-mail:

Diagnosis:
(optional)

5. Agreement
The local chapter agrees to provide the National Organization with copies of all news releases, public statements, proposals, letters and applications, for review and approval prior to release. The local chapter agrees to not represent itself to the public or any agency or other legal entity without prior review and approval by the national organization. No fund raising will be undertaken without express written permission from the National organization.

Signed: ________________________________
(Sign if you are faxing)

Agree:
(Enter name if
submitting online)

6. Release of Information
The individuals who have signed above herewith agree that the National organization shall have the right to perform a background check to determine that no proprosed member is disqualified as a consequence of moral turpitude or illicit behavior.