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Name:
Title:
Organization:
Email:
Address1:
Address2:
City:
State:
Province:
Zip:
Phone:
(work)
(home)
(cell)
Disability Areas of Interest (Please check)
Learning
Development
Visual
Hearing
Physical
Mental
Health/Addictions
Other
Committees of Interest (Please check)
Policies &
Procedures
Conference
Legislation &
Advocacy
Fiscal
Communications
(Website/Newsletter)
Membership
Services
Partnerships
Membership Options: (Please check)
Individual
Member $35.00
• Receives all membership benefits
• Can serve as a Board Member or Committee Chair
• Receives discounted conference fees
• Can serve on one or more Committees
Lifelong Member
$500.00
• Receives all membership benefits
• Can serve as a Board Member or Committee Chair
• Receives discounted conference fees
• Can serve on one or more Committees
Student/Learner
Member $15.00
(Must attach documentation of enrollment in a basic
skill, post secondary, or graduate level program)
• Receives all membership benefits
• Receives student conference fees
• Can serve as a Board Member or Committee Chair
• Can serve on one or more Committees
Organization
Member $250.00
• Receives all membership benefits
• Receives discounted conference fees for up to 10 staff
• Up to 10 staff can serve on one or more committees
• Can designate one staff member to have voting rights
• Can designate one staff member to serve as a Board Member
or Committee Chair
Please identify key contact person for organization in above
field and complete list of members with Email addresses:
Organization:
1. Name:
Email:
2. Name:
Email:
3. Name:
Email:
4. Name:
Email:
5. Name:
Email:
6. Name:
Email:
7. Name:
Email:
8. Name:
Email:
9. Name:
Email:
10. Name:
Email:
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