Membership Registration Form

The membership fee is $40.00 for an individual, families and educators and  $60.00 for healthcare professionals. Your membership fee  includes quarterly newsletters. Fill out the following information and submit on line. You may also print out the form and mail it with check, money order or charge card information for  to:

                 ADDA-SR
                    12345 Jones Road, Suite 287- 7
                    Houston, TX  77070

 
             Name: 
     Occupation: 
Street Address: 
                  City: 
            State: 
        Zip Code: 
      Telephone: 
              E-mail: 
    Employed By:
     Referred By:

I am joining ADDA-SR as a:

 Individual/Family or Educator  $40.00
Parent       Adult with ADHD     Educator     

 Health Care Professional  $60.00 
Doctor      Psychologist   Nurse     Counselor    Social Worker

   I would like to receive the newsletter through email rather than US mail. 

 I would like to donate an additional
as a general donation to ADDA-SR  
as a scholarship.   
in honor of   

in memory of   

YES, I would like to be listed in the newsletter as  

Membership fee:

Donation Amount:

Total Amount:

ON-LINE PAYMENT INFORMATION
 

Mastercard   

Visa   

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American Express   

Card Number: 

    

Name on Card: 

    
Expiration Date:     

Enter your comments in the space provided below:

 

 

 

ADDA-SR

12345 Jones Road, Suite 287- 7,

Houston, Texas 77070

281-955-3720

 

       
 
This page designed by Opal Cummings Harris.
Copyright © 1997 by [ADDA-SR]. All rights reserved.
Revised: 10 Jan 2008 20:41:15 -0600 .