ESCC Membership Application

Thank you for your interest in volunteering with ESCC. Please complete this Member Application in its entirety. Upon completion, you should receive a message indicating that the form has successfully been submitted. If you do not receive a confirmation, please contact the Director of Support Services at 513.791.6230.

This application can also be downloaded as a Word or .pdf document and emailed or faxed to the ESCC office.

Member Application - word format

Member Application - pdf format

If at any time you have questions, please contact the Director of Support Services at 513.791.6230.

*Required

1. Name:
2. Name you prefer to be called:
3. Address:
4. City:
5. State:
6. Zip Code:
7. Home Phone #:
8. Cell Phone #:
9. Business Phone #:
10. Email address:
11. Name of Spouse:
12. Working Status:
13. Education:
14. Most Recent or Current Employer:
15. Length of time with company/organization:
16. Most recent position title:
17. Dates in this Position:
18. Responsibilities:
20. Please list Nonprofits Organizations (charitable, civic, cultural, educational, religious, etc.) you have been involved with:
21. Any additional information or experience that would be relevant to your association with ESCC and its work in the community:
22. How did you become aware of ESCC?:
23. Why are you interested in joining ESCC?: