The Institute for 21st Century Relationships

 I Believe In Your Work! Count Me In!

Please fill out the form completely.  We respect your privacy!  All information is for the exclusive use of the Institute and will not be disclosed or shared with any other organization or entity except in aggregate form.  Items with * are required.

Please provide the following contact information:

Street Address*
Address (cont.)
Zip/Postal Code*
Work Phone
Home Phone

Please describe yourself:

Date of Birth mm/dd/yyyy
Gender* Male Female

What is your current relationship status?*

(Choose one of the following options:)

Married - monogamous (sexually exclusive to one partner)
Married - non-monogamous
Committed partnership (2-3 individuals) - open (not legally wed, sexually open)
Committed partnership (2-3 individuals) - closed (not legally wed, sexually exclusive)
Group marriage (4+ individuals) - open
Group marriage (4+ individuals) - closed
Single (may have relationships other than above)
Prefer not to say

What is your sexual orientation?

(Choose one of the following options:)

Bisexual-leaning Heterosexual
Heterosexual-leaning Bisexual
Homosexual-leaning Bisexual
Bisexual-leaning Homosexual
Prefer not to say

Are you able to help directly in the work of the Institute?

(Select as many of the following as apply:)

I am willing to write letters to the editor
I am willing to appear in news media interviews
I am willing to help with fund raising
I have contacts in the news media I would speak to on behalf of the Institute
I am interested in serving on the Advisory Council (Be sure to read the position description for Advisory Council members first!)
I have a nominee for the Advisory Council
You may publicly cite my name and city/state as a supporter of the Institute
Please send me information to share with others
I can provide speaking opportunities for the Institute

To support our work financially, you can become a part of the Institute family.  Click here for details on levels and the benefits each receive. We are consistently working ideas for new benefits for Institute supporters, and will keep you informed.

(Choose one of the following options:)

Annual Supporter - $10.00
Annual Associate - $35.00
Three-year Associate (SAVE $15.00) - $90.00
Annual Professional Associate - $100.00
Three-year Professional Associate (SAVE $50.00) - $250.00
Organizational/Business Affiliate - $50.00
Patron - $100.00
Russell-Shaw Society Member (Monthly Giving Program)
Benefactor - $500.00
Chairman's Circle - $1,000.00 or more
I will help with a gift of a different amount
I'm a friend, but I can't help financially right now

We are using Paypal to provide us with a secure on-line transaction capability to accept credit cards and other payments.  After completing and sending the above electronic form, use your "Back" button to get back to this page and click here to pay electronically, or you may mail your check, made payable to ITCR/FNCSF, to: ITCR/FNSCF, 822 Guilford Avenue, Box 127, Baltimore, MD  21202-3707.  Contributions to the Institute are tax deductible to the full extent of the law.