Membership Form

Print Form

Name: __________________________________________

Address: ________________________________________

City: __________________ State: ______ Zip:_________

Optional:
Telephone ________________ Fax_________________

Email: ________________________________

Contribution Levels

(Please Check or enter amount where indicated)

Individual Membership
$10 _____   $15_____   $20_____   other $________
Family
$25_____   $30 _____  $35 _____    other $________
Business/Corporate
$50_____   other $_________
Charter
$100 _____

Please Make Check or Money Order payable to:

Mental Health Association in Franklin County, Inc.
552 State Route 86, Paul Smiths, NY 12970

We appreciate all contributions. We are a not for profit agency. All contributors will be placed on our mailing list and receive our newsletter unless otherwise requested.

We do not share or sell our mailing list to other groups or businesses.