Join Us - Families Changing America

Join Us!

Your email address is the only information that is required to join Families Changing America as a Partner for Change.

E-mail Address*

Partner Information (Optional)

We are excited to WELCOME you to Families Changing America as our Partner for Change. You have joined the ranks of many others equally committed to eradicating substance abuse and addiction. In an effort to gather more information about our partners, we ask you to please consider providing us with the following OPTIONAL information.

Either way, be sure to click the submit button at the end of this form to activate your registration as a Families Changing America Partner for Change.

Partner Type Partner Type: Individual Corporate Agency Foundation

First Name
Last Name
Street Address
Street Address (continued)
City
State
ZIP
Country
Occupation

Daytime Phone

Evening Phone

Cell Phone

Reason for Becoming a Partner for Change

If you have lost a loved one due to substance abuse, and you are comfortable sharing that information, please complete the following.

Name of lost loved one
Relationship to you
Gender MaleFemale

Date of Birth (mm-dd-yyyy)

Date of Death (mm-dd-yyyy)

Age at death
Substance involved in death
Would you be interested in speaking publicly about your loss?YesNo

If you have indicated that you are joining as a Company, Agency, or Foundation (Organization) partner, please provide the following information:

Organization Name
Street Address
Street Address (continued)
City
State
ZIP

Daytime Phone

Web Site

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Families Changing America / PO Box 182 / Franklin Park, NJ 08823 / mail@FamiliesChangingAmerica.org