Membership Renewal Form

Fill out the following information and submit on line or print out the form and mail it with check, money order or charge card information to:

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

          Name:
         E-mail:

Note: Change of address or contact information. If you have moved recently or changed your contact information please complete this form .

Street Address:
          County:
              City:
            State:
       Zip Code:
     Telephone:

I am joining ADDA-SR as a:

Individual/Family or Educator $40

Parent

Adult with ADHD

Educator

Health Care Professional $60

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

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ADDA-SR