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.

Membership Level: (Check one)

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

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

____  Client  ( FREE )

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                 $________

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 ____________________________________

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

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.