Name:
Title:
Organization/Agency name:
Mailing Address:
City:						State/Province:		
Zip/Postal Code:				Country:
Telephone:					Fax:			
Email:			
As a service to members VOMA will provide the following information in the membership directory and on the website.  Please indicate here if you do not want this information shared 

Please check all appropriate boxes:
Areas of Practice:
•	Victim advocacy
•	Offender Advocacy
•	Domestic Violence
•	Serious and Violent Crime
•	Court Annexed
•	Reintegration
•	Community
•	Faith-based
•	Schools/Universities
•	Youth
•	Cross-cultural
•	Environmental/public policy
•	Family
•	Indigineous peoples 
•	specify: 
•	Schools and Youth
•	Training and Teaching

	Areas of Interest:
•	Community
•	Restorative Justice (work with victims, offenders, and communities)
•	Environmental/ Public Policy
•	Workplace/ Organizational
•	Research
•	Other     
	Organizational Setting:
•	Court based
•	Government
•	Community based
•	Educational
•	Non-profit
•	Law office
•	Private practice
•	Faith-based
•	Human Rights
•	Insurance
•	Organizational/Workplace
•	Commercial
	
Clients:
•	Victims
•	Young offenders
•	Adult Offenders
•	Community Members
•	Other

	Type of Practice:
•	Mediation
•	Peer Mediation
•	Conferencing
•	Circles
•	Facilitation
•	Training
•	Education
•	Other
	Language:
Services offered in
•	English
•	Spanish
•	French
•	Other 

I am interested in volunteering or working on these issues:
•	Board Committee
•	VOMA newsletter
•	Website 
•	Conference
•	Book reviews
•	Membership
•	Training
•	Fundraising
•	Videos/other resources
Part of VOMA’s mission is to increase the diversity of its membership.  It would help us achieve success with this goal if you provide the following information (Optional):
I am a member of an equity seeking group (please specify):
•	Gender
•	Race/ethnicity
•	Gay/Lesbian/Bi-sexual/Transgender
•	Faith-based
•	Disability