Arkansas Disability Coalition

                  Membership Application

Name___________________________________________________

Organization____________________________________________

Address_________________________________________________

City_____________________________State______ Zip _______

Hm Phone ___________ Wk Phone__________ Extension ___

Fax Number_________________E-mail _____________________

PLEASE CHECK ONE: Low-Income Individuals 

$6 _____  Individual Membership $ 12 ____ and Organization $100 ______

ARE YOU:  Caucasian _____ African American ______  Hispanic________         Native American _____                    Asian _____  or Other _______________

Person With A Disability ______  Parent _______

Guardian ________  or  Relative _____ 

Relationship _______________________________

Type of Disability ___________________________________________________

 Date of Birth (If Under 21) ________________________________________

 Date of Birth of Second Child With A Disability ______________________

 Professional In The Disability Field Yes / No (Describe) _________________

 Other: Yes / No (Describe) ________________________________________

 Interested In Volunteering  Yes / No                                                   

 Phone Calls _____  Grant-Writing _______  Newsletters _____        

Filing ________ Annual Silent Auction _______

Special Needs: Regular Print _____  Braille _____                 

Cassette _____ Computer Text File _____ Large Print _____

Signature ________________________________________

Date _____________

Please mail this application form in with your check or money order to:

Arkansas Disability Coalition  

1123 S. University Avenue Ste 225

Little Rock, Arkansas  72204