Membership Application for the Learning Disabilities Association of Kansas

Complete Form and Mail to:

LDA of Kansas
P.O. Box 4424
Topeka, KS 66604

Check one:
(  ) New     (  ) Renewal

Name __________________________________________________

Address ________________________________________________

City ___________________________ State ______ Zip __________

Phone (Home) _________________   (Work) ___________________

e-mail _____________________________

Please check appropriate category:

(  ) Parent
(  ) LD Adult
(  ) Professional (specify)
(  ) Other (specify)
________________________________________________________________________

Enclosed are annual dues of $35.00
(Includes national, state, and local membership)
Make check payable to LDAK
Enclosed is an additional contribution of $ ___________.
Dues and contributions may be treated as charitable contributions for Federal Income Tax purposes.

(  ) Send additional information about LDAK.

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