CERTIFICATION REQUEST FOR TEEN HELP PROVIDERS

In order for Teen Help Providers to become a Member of Certified Teen Help Organization, information must be submitted concerning the specific services you provide as well as contact information.

_{This information will remain confidential with respect to the Teen Help Provider's rights, and will only be used to accomplish the services that CTHO has specified to the Teen Help Provider through the Questionnaire & terms and conditions.}

AUTHORIZED CONTACT PERSON INFORMATION
1. First Name
2. Last Name
3. Cell Phone
4. Business Phone
5. Email Address
ORGANIZATION INFORMATION
6. Organization Name (Do not include apostrophes (') in your Organization Name)
8. What type of teen help provider are you?	18 and Over Boarding School Boot Camp Religious Boarding School Therapeutic Boarding School Eating Disorder Treatment Military Academy Outdoor Therapy Private School Residential Treatment Center Teen Pregnancy Wilderness Program Youth Transport Educational Consultant
9. What genders do you serve?	Male Female Co-ed
10. What ages do you serve?	11 and under 12-17 18 and over
MAILING ADDRESS
13. Address
14. City
15. State	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming --- Canadian Provinces --- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ------------ International Mexico
16. Zip
PHYSICAL ADDRESS
17. Address
18. City
19. State	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming --- Canadian Provinces --- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ------------ International Mexico
20. Zip
ORGANIZATION CONTACT INFORMATION
21. Business Phone
22. Fax Phone
23. Toll Free Phone
24. Website Address
25. Email Address
ADMISSIONS INFORMATION (if applicable)
26. Contact Name
27. Email Address
28. Phone Number
COMMENTS AND QUESTIONS
29. Comments and Questions
TERMS AND CONDITIONS
30. Terms and conditions (This must be checked)	I AGREE to the terms and conditions I do NOT agree - do NOT process this request
Enter the characters you see here: (No Zero's)