membership/application

The Arc of Pitt County - Membership Application

Date: _____________________

Name: ________________________________________________

Address: ____________________________________________________________

State: ______ Zip: ___________

Telephone: (Home) ___________________________

(Cell) ___________________________

E-mail: ________________________________________________

Would you prefer to receive mailings ( Workshop Notices, Announcements, Flyers, etc.)

via E-MAIL or REGULAR POSTAL MAILINGS? (Please circle your preference)

*Date of Birth: ___/___/____ *Optional. Our funding sources request

*Date of Birth: ___/___/____ age of any persons with developmental

disabilities in your home.

Please check the categories that apply:

_____Parent

_____Family Member of a person with a disability

_____Self-Advocate (person with a developmental disability)

_____Professional in the MR/DD field

_____Interested Friend

_____Corporate Sponsor

Membership Categories: (Please check one):

________Student $10

_______Self-Advocate $10

________Individual/Family $20

_______Sponsor $35

________Patron $50

_______Arc Angel $100 or more

If paying by check please make out to : The Arc of Pitt County

The Arc of Pitt County

2408 S. Charles Blvd., Ste. 1 Ph. (252) 756-1056