Exceptional Families Network Membership

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NOTE:
In compliance with state and federal regulations, we are required to obtain personal information, in order to give you a discount on our services. Your information will be kept on the file and in strict confidence. Income must be verified annually. Please provide proof of family income, including but not limited to an income tax return, w-2 form, paycheck stubs, copies of your social security checks, or other checks you may receive.
Only family size and annual income will be used to determine eligibility and calculate your discount. Families will not be denied access due to inability to pay.

Email *

Parent/Guardian Name *

Home Address *

City *

State *

Zip *

Primary Phone *

Membership Fees (please initial payment option): *

$25 per quarter ($2 quarterly processing fee will be applied)

$100 per year (no processing fee with yearly membership paid infull)

I'd like to volunteer 24 hours per year instead of paying a fee

I'd like to reduce the amount - for every hour you volunteer, reduce your membership fee by $5

I'd like to be considered for a sliding scale fee schedule

Household Size *

Number of individuals above age 18 *

Number of individuals below age 18 *

I would like more information on programs in my community *

Yes

Send me a copy of my responses.

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