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LDA State Affiliates

 Membership

LDA of WNY Membership Application Form

FIRST NAME:

LAST NAME: 

ADDRESS:      

CITY, STATE & ZIP:

PHONE:         

E-MAIL:          

  FAMILY RATE                                      $ 50.00

  PROFESSIONAL RATE                       $ 100.00
       

  ORGANIZATIONAL RATE                  $ 400.00
       

Please return this form with payment to:

LDANYS
1190 Troy-Schenectady Rd.
Latham, NY 12110

Organizational members please list up to 4 additional contacts.

Membership and donations are tax deductible; 
receipts will be forwarded with your
'LDA Membership Card'

THANK YOU FOR YOUR SUPPORT

Learning Disabilities Association of WNY
2555 Elmwood Avenue
Kenmore, New York 14217

716.874.7200    or    800.250.5031
e-mail:  information@ldaofwny.org


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