The Maryland Association of Community Services (MACS)
for Persons with Developmental Disabilities, Inc.
10632 Little Patuxent Parkway, Suite 254 # Columbia MD 21044
410-740-5125 (Baltimore/Annapolis); 888-838-6227 (DC Metro); 410-740-5124 fax
http://www.macsonline.org Email: macs@macsonline.org
FY 2010 Agency Membership Application
Please print all information as you wish it to appear in our membership directory.
AGENCY NAME:______________________________________________________________________
Executive Director:_____________________________________________________________________
Proxy: ______________________________________________________________________________
ADDRESS:___________________________________________________________________________
Mailing Address & Suite Number or PO Box
____________________________________________________________________________________
City State Zip
TELEPHONE _______________________________ FAX____________________________________
EMAIL: _______________________________ Website: ______________________________________
Geographic region agency serves: _______________________________________________________
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Types of supports agency provides |
# served |
Adults |
Children |
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Group Homes (4 or more) |
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ALUs (3 or fewer) |
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CSLA |
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Supported Employment |
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Day Habilitation |
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Medical Day Care |
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Resource Coordination
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Agency funding sources: ______________________________________________________________
Locations of other offices: (use back if necessary) _______________________________________________
Number of years agency has been operating: ______________________________________________
Number of full time staff: ______________________ Number of part time staff: __________________
MACS has several e-list-servs for information exchange with various committees. The information you provide below will help MACS to better inform our members about important issues.
Most information is emailed. Please indicate the appropriate person if someone other than the executive director is to receive info concerning the following:
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Position |
Name |
e-mail |
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Public Policy |
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Quality Assurance |
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Training |
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Nursing |
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Res/CSLA |
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Sup. Emp |
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Day Habil. |
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Medical Day |
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F/ISS |
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Resource Coordination
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Children |
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CFO |
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HR |
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Please return this form via mail or fax to the MACS office along with your dues application or renewal.
Print