2018-2019 Let's Talk LD Individual/Family Membership Application
Application for Membership
Email address *
Primary Member Information
First Name
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Last Name
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E-Mail Address
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Current Mailing Address
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City
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State
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Zip Code
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Birthdate
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Home Phone
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Cell Phone *
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Partner/Spouse Information
Partner First Name
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Partner Last Name
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Partner E-Mail Address
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Partner Birthdate
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Partner Cell Phone
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Children Information (If Membership Privileges Desired)
Child1 FirstName
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Child1 LastName
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Child1 Grade Level
Child2 FirstName
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Child2 LastName
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Child2 Grade Level
Child3 FirstName
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Child3 LastName
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Child3 Grade Level
Child4 FirstName
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Child4 LastName
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Child4 Grade Level
Signatures
You authorize Let’s Talk LD to include you on their Mailing List (YOU OPT IN). You will receive news, updates, and information about Let’s Talk LD and its programs. You understand that this membership is valid through September 30, 2019. If you wish to cancel your membership, you agree to do so in writing by emailing Membership@LetsTalkLD.org. Membership fees are non-refundable. We value your privacy and will not sell your info to 3rd parties.
Electronic Signature (Please Type Your Name)
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Application Date
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MAILING ADDRESS: Let's Talk LD | P.O. Box 1015 | South Pasadena, California 91031-1015 | http://www.LetsTalkLD.org | 626.644.0740
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