Membership Form

1. Personal Information

Membership request type*

New Member
Renewing Member

Date*

Name*

First Last

Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone*

If you have a child with LD's and/or ADHD:

Child's Name (Optional)

Age

Disability (Optional)

School

2. Annual Membership Costs & Donations

*Membership expires December 31st. New members may be eligible for pro-ration after Sept. 1st.

Membership requested*

Individual/Family
Post Secondary Student or Senior (65+)
School
Corporation

Donation Option:

If you would like to provide additional support for our programs:

Donation to LD Edmonton :

Where would you like your donation directed to?

Direct my donation to the greatest need
Direct my donation to:

Direct to:

Total: (Donation & Membership)

$ 0.00 CAD

LD Edmonton will contact you for payment information within the next 2 business days. Thank you so much for your interest in becoming a member.

3. Reason for Membership

Reason for membership

LD Edmonton Programs
Parent of a child with LD/ADHD
Student
Supported Adult
Adult with LD/ADD
Professional
Other

Other:

4. Ways you'd like to volunteer

Ways to volunteer

Office Help
Casino
Special Events
Fundraising
Other

Other:

5. How to Stay in Contact

Stay in Contact

Monthly E-news
Quarterly Perspectives Magazinne
Bi-Annual Donor/Funder Update
Everything
Nothing

LD Edmonton values the privacy of its members and will not release your information to other organizations. LD Edmonton gathers information about its members in order to provide ideal programs and services. Charitable #11901048RR0001