IDA MEMBERSHIP

NAME:

First:

Last:

ORGANIZATION:

RENEWAL:

Yes No

ADDRESS:

Street:

ADDRESS 2:

Suite / Floor:

City:

State:

Zip:

DATE OF BIRTH:

Month:

Day:

Year:

TELEPHONE:

Day: (area code)

Evening: (area code)

E-mail:

Fax: (area code)

Dyslexic Family Member? (if applicable): Spouse Self: Child Sibling

CATEGORY:

YES, I would like to RENEW/REGISTER my membership in IDA at the membership level checked:
(check one only):

Individual $ 70

Individual / Sustaining $150

Individual / Supporting $300

Family $110

Institutional $295

Lifetime $2000

Corporate - Level 2 $295

Corporate - Level 2 $795

College Student $ 40

Retired $ 45

PROFESSIONAL INTEREST:

PLEASE, check the category that BEST describes your occupation or professional interest:

Advocate / Lobbyist

Parent

Attorney

Physician

College Student

Psychologist

Corporation / Organization

Reading Specialist

Educational Administrator

Research / Educational

Educational Diagnostician

Research / Medical

Individual with Dyslexia

Special Education Teacher

Parent/Other Family Member of Individual with Dyslexia

Speech - Language Pathologist

Educational Therapist

Tutor

Teacher Secondary

Other:

Membership Mailing List Rental

At times, the IDA membership list is made available to other
organizations whose products or services we think our members might find of interest. If you do not want your contact information included on these mailing lists, please check here.

LD Service Provider Database

IDA maintains a list of service providers for people who contact us for resources. If you would like to be on this list and receive an application, please check here.

Your listing will remain on the service provider list as long as your member ship is active.

PAYMENT METHOD

Credit Card:

Card Number:

Expiration Date:

Card Holder’s Name: