Yes, I want to join CHADD, Monroe County,
Indiana (chapter 665)
New Member Renewal Membership
Name
____________________________
Address ____________________________
City
____________________________
State
__________ ZIP _____________
Daytime Phone ______________________
Evening Phone ______________________
E-mail
____________________________
Occupation/Title
____________________
Membership
Categories
Student ($35)
Family or Educator ($45)
Health Care Professional ($75)
I would like to donate a membership
for
someone less fortunate ($45)
Payment
(All funds received must be in U.S. Dollars)
Check
Mastercard
Visa
Money Order
American Express
Name on Card _______________________
Card Number _______________________
Expiration Date ______________________
Signature ____________________________
Please
Mail to:
CHADD
8181 Professional Place
Suite 201
Landover, MD 20785
Attn: Chapter 665, Monroe County