Mental Health Association of Volusia and Flagler County

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Membership Application Form

TOGETHER, THROUGH ACTION AND BY COMMITMENT
"WE DO MAKE A DIFFERENCE"

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Please Print this form, fill in your information and mail to the address provided at the bottom.
You may also call in or fax your information to our office if you wish.
Click Here for Print Friendly Version

Contact Information:

Name _______________________________________

Company ____________________________________

Address _____________________________________ City _____________________ State ___ Zip _______

Phone _______________________________________

E-mail _______________________________________ (Optional)
By providing an e-mail address, I am indicating that I desire to receive e-mail updates from the organization on a regular basis.

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Membership Level: (Check one)

____ Individual  ( $ 35.00 )            ____ Family  ( $ 50.00 )

____ Professional  ( $ 75.00 )       ____ Corporate  ( $150.00 )

____ Client  ( FREE )

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Membership Totals:

Total Membership Dues (from Membership Level above)              $_________

I wish to donate an additional amount (optional)                              $_________

I wish to contribute to assist in providing free memberships for clients (optional) $_________

Total Amount Enclosed                 $________

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Method of Payment:

____ Cash ____ Check ____ Credit Card

If you chose to pay by Credit Card, please fill in info below:

____ MasterCard ____ VISA ____ Discover ____ Amer. Exp.

Card # ______________________________________

3-digit Code ________ Exp. Date ________________
(from back of card)

Name _______________________________________
(as it appears on card)

Signature ____________________________________

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Delivery Options:

Once you have filled in the above information you can mail this form to:
                                MHA of East Central Florida, Inc.
                                531 S. Ridgewood Avenue
                                Daytona Beach, FL 32114

Charge Card orders may also call in or fax your information:
Phone: 386-252-5785
Fax: 386-255-7560

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The Mental Health Association of East Central Florida, Inc. is a non-profit 501(c)3 corporation. Thank you for your tax deductible contribution and support.

____ I am interested in learning more about volunteer opportunities.

531 S. Ridgewood Ave., Daytona Beach, FL 32114
Phone: 386-252-5785 Fax: 386-255-7560
Website: www.mhavolusia.org