Questionnaire for Member of Educational Network


The following questions are intended to provide us with an accurate representation of
your institution. This information will help ensure a compatible placement of a Client. If you
need more space to answer any of the following questions, please feel free to send an additional
email message after you complete the Questionnaire. A convenient notepad and a
direct email link will be provided at the end of the Questionnaire.

The Nurturing Network respects the privacy of all our Members. Your completed questionnaire
will remain on file at our office and will not be photocopied except for the internal use of
The Nurturing Network, Inc. We will share with Clients only the information we believe might
help our efforts to make an appropriate referral. If there is any specific information
which you wish not to be revealed, please make a note in the margin beside your response.

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	Date	/ /
A. Basic Information
	Please update information to accurately reflect the current status of your institution. Source of the information is the Higher Education Directory.
	Name of School, College, University:
	Address:
	City/State Zip:
	Mailing address (if different from above):
	Phone:               ()      Fax:    ()
	Email address:
	Enrollment:
	Accreditation:
	Name of President:
B. Acceptance of Membership in the Nurturing Network
	is pleased to accept membership in the Nurturing Network.   Name of College/University Key
	Has the Administrative staff involved in this decision read and understood the Client and Member brochures which describe The Nurturing Network? Yes No
	Are the Administrative staff involved in this decision comfortable upholding the purposes of The Nurturing Network? Yes No
	Are the Administrative staff involved in this decision capable of providing the supportive academic environment that your Client(s) need? Yes No
	The Administrative staff involved in this decision requests additional information. Specifically, we would appreciate a phone conference with the Manager of Educational Resources. Yes No
	Staff member to contact:
	Name:
	Title:
	Phone:	()