Organizational Membership Form

* Required Information

Please provide the name of your organization: *

Please provide the address of your organization *

Organization main phone number:

Fax number:

For the following items please provide information for each representative joining YCSNDC from your organization.

Full name of representative *

Email address of representative *

Preferred phone number of representative *

Add more representatives...

In the space below, please let us know how many total individuals from your organization are joining *

Please check at least 1 committee that you would be interested in having your organization participate in and if you don't see one, feel free to generate a new committee in the "Other" field

Advocacy/Public Awareness

Family Involvement

Service Partnership

Other

Other Committee:

Please select how you will be submitting your annual dues ($60 for 3 representatives or $100 for 5 representatives): *

Paypal: to pay using this method, go to http://www.kidcocreativelearning.org/, click on the pink “donate” button, fill in the form, and then click the pink “complete donation through PayPal.” PayPal will prompt you to include your address. Once you've submitted your payment you will receive a receipt to the email address you have registered with PayPal. Please send this receipt to Myrna at myrnac@arcsofla.org & Amanda at aley@advocacynetwork.org

If you would like to submit your dues via check, please make check out to: Kidco Creative Learning Inc. and submit at your earliest convenience.

Mailing Address for Checks:

Attention to Silvia LaVilla

761 E. Okeechobee Rd. Hialeah, Florida 33010

Attention: Silvia LaVilla

As a paying member I understand that specific information will be posted on the YCSNDC website. Please select whether you agree to website listing. Select "Other" if you would only like limited information shared and specify what you would like posted.

Yes

Other

Other information