2008/2009 Membership Form

Name:

Address:

City/State/Zip Code:

Home Phone Number:

Cell Phone Number:

Email Address:

School(s) My Different Learner(s) Attend:

School(s) My Other Children Attend:

Would you like to be in a Membership Directory for publication?  Yes  No

Circle the areas you are interested in helping with:
Hospitality           Library/Resource Information         Newsletter Circulation  
Mentoring Committee         Disability Awareness Workshop        Publicity
Friends Appreciation Awards (June)         School Representative  
Membership         Camp Fair

Are you a: ___Parent   ___Educator   ___Other________________________

Other organizations you are associated with:

Donations in kind ____________ ($, time, copying, etc.)

Annual Dues are $20.00.

Please make checks payable to "Friends of Different Learners" and mail with a copy of this form to: Friendsof Different Learners, P.O. Box 233, Birmingham, MI 48012-0233.

Friends of Different Learners is a 501 (c)(3) tax-exempt organization.