Kentucky Disabilities Coalition
Membership Form

Date: _____/_____/_____
Please Check Affiliation Type and Enclose Applicable Annual Tax Deductible Donation:
New Affiliation _____ or  Renewal Affiliation _____   (Annual Affiliations run from July 1st – June 30th)
$10 Individual Membership _____
Organization Memberships:
$25 Non-Profit, Local/Regional _____;    $100 Non-Profit, Statewide _____;    $100 Gov. Agency _____
For-Profit or Other Non-Member Sponsor Organizations: 
$150 KY Local/Regional _____;    $250 KY Statewide _____;    $500 National or National Affiliate _____
General Information
Name:  Ms./Mr./Dr. ____________________________________________________________________
Mailing Address: ______________________________________________________________________
City: _________________________________________  State: _________  Zip: ___________________
Preference:  Work Phone: (_____)__________________  Home Phone: (_____)____________________
Email Address: _______________________________________________________________________
Disability Organization Affiliation (if any): ___________________________________________________

Personal Information (Optional)
Do You Have a Disability? 	Yes:  _____	No: _____
If Yes, Please Describe: ________________________________________________________________
Do You Need Written Materials in Alternative Format?	Yes: _____	No: _____
If Yes, Please Specify:	Large Print: _____	Braille: _____        Recorded:_____
How did you hear about KDC? ___________________________________________________________
Organization Information
Please Complete General and Personal 
Information for Designated Representative

Business/Organization Name: ___________________________________________________________
Mailing Address: ______________________________________________________________________
City: _________________________________________  State: _________  Zip: ___________________
Designated Representative (For Member Organizations): ______________________________________
Nature of Organization  (Check All That Apply):
Service Agency ____; Government Institution ____; Educational Institution ____; Medical Institution ____
Disability-Related Organization ____;  Private Sector Organization ____;  Other ____________________
Number of Persons Represented by Your Organization: ____________   (For Demographic Information)
(Revised 6/18/02)
• • • • •
Please Make Your Checks or Money Orders Payable to the Kentucky Disabilities Coalition
Please Return Membership Form and check or Money Order to:
Kentucky Disabilities Coalition • P.O. Box 1589 • Frankfort, KY  40602-1589