LEARNING DISABILITIES ASSOCIATION OF IOWA
MEMBERSHIP APPLICATION

I am enclosing membership dues of $40 for a ____ renewal or for a  ____ new membership.

I am enclosing dues of $25 for a Student Membership. ______

NAME_______________________________________________________________________

HOME ADDRESS_______________________________________________________________

CITY____________________________________ STATE__________ ZIP________________

HOME PHONE (_____)_________________ AEA______ EMAIL_________________________

Please check the one category that best describes your interest in learning disabilities:

___Parent   ___Professional  ___Student  ___Other (Please specify)______________________

****I would like to support the goals and projects of LDA-IA.  Enclosed is a donation of $_______.
 

Please make your check payable to LDA-IA and mail to: LDA-IA,  5665 Greendale Rd, Ste. D, Johnston, IA 50131