Learning Disabilities Association of Pennsylvania

(Print or Type)

Name _________________________________                                             

Telephone:  Home ______________________ Work_________________

Address _____________________________                                                  

City ________________________________ State ______ Zip _________ 

School District ________________________________________               

County  ______________________________                                                  

 
E-mail _______________________________                                                 

Please check appropriate area(s):

___       Enclosed are annual dues of $35.00 (includes national, state and local)

                          Check enclosed made payable to LDAPA

                           Payment by credit card

                              Visa                   Mastercard                  

                              Card Number                                                                     

                              Expiration date                                                               

                              Signature                                                                        

                                                                                    Total amount charged                 

___Enclosed is an additional contribution of $______________

Please print this form and mail to:

LDA of Pennsylvania
Toomey Building
Post Office Box 208

Uwchland, PA 19480

Current members will receive a renewal notice from LDA of America.

Dues and contributions may be treated as charitable contributions for Federal Income Tax purposes.