asdc@deafchildren.org Parent Information and Referral Line: (800) 942-ASDC (2732)
MEMBERSHIP FORM Name:__________________________
E-mail: ___________________________
Address: __________________________________________________________ City: ___________________________
State:____________
Phone:
Zip:__________
Voice/TTY/Videophone
Membership Type Individual memberships _______$40 per year: Individual/Family Membership _______$100 per year: Three-year Individual/Family Membership _______$5,000 one-time fee: Lifetime Membership _______First-Year Free Membership (Families with deaf or hard of hearing children are eligible for a FREE one-year membership. Just fill out this form and mail, e-mail or fax it back to us.) Deaf or Hard of Hearing Child’s Name: ___________________________________ Date of Birth ___________________________________ Group memberships _______$250 per year: Parent Affiliate Group ( ____ Number of Parent Members) _______$125 per year: Library Membership _______$250 per year: Educational Membership _______$250 per year: Organizational Membership I would like to send more than my membership dues. Enclosed is a tax-deductible donation: $10 $25 $50 $100 _______Other Total Enclosed: $__________ Make checks payable to American Society for Deaf Children. Please charge my Visa or MasterCard: Card Number:_________________________________Expiration Date:______________ Please return to: American Society for Deaf Children #2047 800 Florida Ave. NE, Washington, D.C. 20002-3695 FAX: (410) 795-0965 • Phone: (800) 942-2732 • E-mail: asdc@deafchildren.org
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