Membership Application 

Approved by YPA Membership on December 3, 2008.





name

Membership Application

Date: 

Company:

Primary Representative:

Full Physical Address:

Mailing Address if Different:

Primary Representatives Email:

Phone:

Additional Representative (include email address): 

Type of Service Provided (mark all that apply)
Proctor Care 
Outpatient 
Residential  
Tracking/Mentoring 
Independent Living  
Therapy  
In-home Services  
Professional Parenting  
DSPD 
Other  
Diagnostic Specialty (mark all that apply)
Substance Abuse 
Co-occuring Diagnosis  
Mental Health  
Behavioral Health  
Eating Disorders 
NOJOS 
Victims of Domestic Violence 
Other  

Number of Full Time Equivalent Employees:

Dues Owed:

Annual Dues Structure (Charged Monthly)

Full Time  Equivalent Administrative & Direct Care Youth Services Employees

       FTE Employees--------------------Annual Dues ---------Monthly Charge

          1 - 20---------------------------$600--------------------$50

         21 - 40-------------------------$1200-------------------$100

          41 - 80 -----------------------$ 1,800-------------------$150

          80 - Plus -----------------------$2,400 ------------------$200

I would like to pay my annual dues by:
paying monthly with automated ACH payments and receive a 5% discount.  
paying full amount of dues owed in a single payment.  

Please complete the following questions as part of your application.

These questions enable YPA to promote your membership and the Association as having the highest of standards within the industry and the community.  All answers remain confidential and will not be distributed.

1. This agency passed our state audits during the past two years.
Yes  No 
 
2. Within the last two years, this agency has been successful in not being placed on moratorium and/or sanctioned.
Yes  No 
 
3. Within the last two years, this agency has been successful in not having its license suspended or revoked.
Yes  No 
 
4. This agency is in good standing with the Utah Department of Human Services.
Yes  No 
 
This agency providers Trauma Informed Care.
Yes  No 
 
This agency uses an outcome data collection tool to drive treatment.
Yes  No 
 

If yes, please identify the tool(s) used within your agency. 

This agency uses an Evidence Based Practice model to drive treatment.
Yes  No 
 

If yes, please identify the model used. 

This agency employs individuals with areas of specialized expertise who are willing to provide training to other YPA members.
Yes  No 
 

If yes, please identify areas of expertise. 

This agency agrees to provide anonymous feedback and participate in surveys sent by the YPA throughout the year.
Yes  No 
 

Comments:

Application Completed by:

Title:

Please submit your Membership Application. YPA administration will contact you regarding the status of your application within two weeks.  A YPA Membership Certificate wll be presented to your agency upon approval of the Membership Application and a completed ACH setup for dues owed.  

Thank you for your membership!

Youth Providers Association, Inc.

 

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