Membership Application

*Name:

*Address:

*City:

*State: Select a State Military Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

*Zip Code:

*Email:

*Phone:

*The following information will allow us to serve our members better-please check box
most appropriate (This information will NOT be listed on the membership page):

Age of Member

1 to 24     25 to 34     35 to 44     45 to 54     55 to 64     65+    

Classification

 Parent / Relative*  Self Advocate  Professional In-field  Caring Citizen

*If parent of person with developmental or cognitive delay; age of person:

I would like to work with The Arc on (check any that apply):

 Membership  Organizational Issues  Prevention  Public Awareness
 Education  Governmental Affairs  Inclusion  Fund Raising
 Research  Assistive Technology  Other:

Other:
(If checked)

I would also like
information on:

*Security Answer?: