"*" indicates required fields Prevention Council Re-Chartering AgreementThis document establishes the agreement between Prevent Child Abuse Indiana, a Division of The Villages, (heretofore referred to as "PCAIN") and (type Your Council's Name)Name of Council* (heretofore referred to as "PCAIN Chartered Council") for the period of January 1st to December 31st. The Agreement The agreement between PCAIN and all PCAIN Chartered Councils is based on the mutual understanding that we will continually work together to build a statewide organization and network that enables all sectors of the community to play a significant role in preventing child abuse and neglect. Mutuality of Agreement In affirmation of our agreement, both PCAIN and the PCAIN Chartered Council will support and promote one another to the greatest extent possible. It is respectfully understood that each of our activities in some way reflects on Prevent Child Abuse America (PCAA) as well as our state and local images. Each entity must take great care to ensure that our actions correspond with the vision, core values, guiding principles and position statements established by PCAA. PCAIN Responsibilities PCAIN has a commitment to provide technical assistance to Chartered Councils, resources permitting. Chartered Councils will receive all established benefits, outlined in Appendix A. Council Responsibilities Chartered Councils are expected to maintain compliance with the criteria for PCAIN Chartered Councils throughout the charter period (Appendix B). Should there be any major change in a Council’s organization or in its ability to be in compliance with the criteria, the Council agrees to notify PCAIN in writing within sixty (60) calendar days. The Charter This charter acknowledges that the PCAIN Chartered Council is in compliance with the criteria of PCAIN and is granted annually. When a charter is granted, the PCAIN Chartered Council will pay a yearly Chartering Fee. Chartering fees are not refundable. Appendices The Appendices (A through H) are considered an integral part of this Chartering Agreement and can be accessed on the PCAIN Council Portal at www.pcain.org under Council Documents. Certification As an authorized officer ofAuthorized Officer* Agreement* I agree that our Council's Officers will review the Appendices yearly.*I hereby certify that our organization is applying to be a Chartered Prevention Council of Prevent Child Abuse Indiana. I further certify that we understand this agreement (including all Appendices) and that we will maintain compliance with it.Your Name* First Last Person filling out the Chartering AgreementCounty / Counties Served* Primary Contact InformationThis information will appear on the Prevent Child Abuse Indiana website so that people can contact your Council. It is important that the contact person is available to receive information. We will also use this information to send postal mail.Responsibilities of the Primary Contact Person are:Be available to the PCAIN Staff through email and phoneAct as the messenger to the rest of your Council’s Officers and VolunteersNotify PCAIN Staff of any Officer or Contact changesPrimary Contact Person* Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Preferred Phone*Preferred Phone Type* Home Work Cell Alternate PhoneAlternate Phone Type Home Work Cell Shipping Address Same as Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Description of Council Activities (to be used on PCAIN website on your council page)* Does your Council operate under the umbrella of another organization and use their 501c3?* Yes No Name of that Organization Federal Tax Exempt # When do you usually hold your meetings?* Day of the Week*MondayTuesdayWednesdayThursdayFridaySaturdaySundayWeek of the Month*FirstSecondThirdFourthTime* Hours : Minutes AM PM AM/PM Meeting Location* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Anticipated needs for the coming year* Strategic Planning Volunteer Recruitment Board Orientation No needs at this time Other Other Needs* Do you want a free box of prevention brochures?* Yes No (100 of each English Brochure – will send to street address indicated above)Do you want your April Brochure Box* I do not need the April Brochure Box. Yes, please email me the form to order. Your choice - up to 20 packages (50 per package) in English or Spanish. Would you like your Chartering Certificate...* Emailed to Me - I print Printed copy mailed to me? Board OfficersRemember, if you change Officers or the Main Contact throughout the year to notify PCAIN by using the "Change of Officers" form ASAP. That form is located on the PCAIN website, on the Council Documents Page.PresidentPresident Name* First Last President Term Ends Month Day Year President's Email* President's Preferred Phone*Preferred Phone Type* Home Work Cell President's Alternate PhoneAlternate Phone Type Home Work Cell Vice PresidentVice President Name* First Last Vice President Term Ends Month Day Year Vice President's Email* Vice President's Preferred Phone*Preferred Phone Type* Home Work Cell SecretarySecretary Name* First Last Secretary Term Ends Month Day Year Secretary's Email* Secretary's Preferred Phone*Preferred Phone Type* Home Work Cell TreasurerTreasurer Name* First Last Treasurer Term Ends Month Day Year Treasurer's Email* Treasurer's Preferred Phone*Preferred Phone Type* Home Work Cell Please notify PCAIN of any Officer Changes throughout the year Board Members / Council Volunteers Please provide the names and contact information for other members/volunteers of your Council who do not serve as officers. We use this list when sending out the Council Courier Enewsletter every other month. Our lists are not shared with other persons/organizations outside of PCAIN. You may also email your member/volunteer list to the PCAIN Administrative Assistant at kking.pcain@villages.org (Excel Spreadsheet preferred).Please fill out (emails will only be used to send out the bi-monthly Council Courier Newsletter)*NameEmail Add RemovePinwheel Ordering/Shipping InformationEach Chartered Council may receive up to two boxes of pinwheels at no charge. Each box contains 240 pinwheels, a total of 480 pinwheels. Please determine whether two cases will work for you.How many FREE boxes of pinwheels does your Prevention Council want to order for the upcoming year (240 pinwheels per box)?*NoneOneTwoIf you need MORE than two cases, each additional case will cost $100 each at the time of rechartering. If you need more throughout the year, please order them from the PCAIN Website SHOP Page at a cost of $180 per box (minus the 25% discount) plus a shipping charge of $25.Do you need additional boxes of Pinwheels?* Yes No How many additional boxes do you need? $100 Per box (240 pinwheels per box) Quantity Price: $100.00 Quantity Pinwheel Shipping Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pinwheel Shipping Phone (if needed by the Delivering Company)*Pinwheel Shipping Email* Payment ChoicesHow will you pay?*Credit Card (via Square)Check (to be sent ASAP to the PCAIN Office)Credit Card* Cardholder Name Card Details Chartering Fee* Price: Total Chartering fee plus additional pinwheel boxes.When paying by check, be sure to add the chartering fee of $150.00 plus $100.00 for each pinwheel box. Ex. if you are ordering 3 pinwheel boxes, your total would be$150.00 + ($100.00 x 3) = $450.00
