2020-2021 Let's Talk LD Institutional/Community Partner Membership Application

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Application for Membership

Email *

Primary Member Information

First Name *

Last Name *

E-Mail Address *

Current Mailing Address *

City *

State *

Zip Code *

Work Phone *

Cell Phone *

How many members of your organization (approximately)? *

How many members of your organization would you like to be included in your Let's Talk LD Membership? *

Signatures

You authorize Let’s Talk LD to include you on their Mailing List (YOU OPT-IN). You will receive news, updates, and information about Let’s Talk LD and its programs. You understand that this membership is valid through June 30, 2021. If you wish to cancel your membership, you agree to do so in writing by emailing Membership@LetsTalkLD.org. Membership fees are non-refundable. We value your privacy and will not sell your info to 3rd parties.

Electronic Signature (Please Type Your Name)

Application Date

YYYY

MAILING ADDRESS: Let's Talk LD | P.O. Box 1015 | South Pasadena, California 91031-1015 | http://www.LetsTalkLD.org | 626.644.0740

A copy of your responses will be emailed to the address you provided.

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