Breakthrough Staff Exit Form

This form is used to inform the National Office of staff transitions at our affiliate sites. When a staff member transitions out of their role, please complete the below form so we can update our staff rosters and ensure that the appropriate communications continue to reach your site. Thank you for helping us keep our staff rosters updated!

Should you have any issues with the form, please contact Tori Perrakis at (tperrakis@breakthroughcollaborative.org).

Exiting Staff Member Information

Breakthrough Organization

First Name

Last Name

Breakthrough Email

Title

Approximate End Date

Incoming Staff Members

Remember, all incoming staff members should fill out the Welcome New Staff Member form, located here. This ensures that the new staff member receive all critical National Office communications, including the Collaborative Connection.

If the role of the staff member listed above has already been backfilled, please enter your new staff member's name below.

Contact Information