Membership Application 2005-2006

Title: O Ms. O Mrs. O Mr. O Other ______________

First Name: ____________________________________Last Name____________________________________

Address 1: ____________________________________Address 2:_____________________________________

City: ________________________________________ State: _______________Zip: ______________________

Phone: _______________________________________E-mail: _________________________________________

Choose a password: ___________________________________School (if student) _______________________

Areas of interest: O AD/HD O Autism spectrum O Developmental O Deaf/Blind O LD/NLD O MR/Cognition

O Physical disability O Medical O All O Other __________________

Age levels of interest: O Preschool O K-early elementary O Mid elementary O Middle School O High School

O Post High School O Transition, 18-22 O College O All O Other ____________________

Membership Categories

Membership categories are for individuals, parents, families, professionals, students, and parent advisory councils. If you are an agency, business or organization (+1 employee), or looking to expand parent outreach, please refer to the Associate Member Membership program.

All members receive the newsletter, a biweekly e-news update, member package with guides and publications, one educator/appreciate certificate, access to the listserve website member area, access to the lending library, discounts on publications/products, and a gift.

Donors & professionals also receive a discount for advertising in the online PDR-Professional Directory of Resources.

Donors will also receive a Wrights Law book. See the Media Kit for further information.

PAC members are entitled to all the above, receive an expanded resource package, access to PAC Training Institutes, in-district workshops, and have up to three officers access the listserve and website.

Category 1 year rate 2 year rate

Individual / family O $ 40 O $ 70

Professional (individuals only) O $ 100 O $ 185

Donor (individuals only) O $ 150 O $ 280

Parent Advisory Council (please use PAC form) O $ 190 O $ 350

Student (undergrad or graduate) O $ 40 O $ 70

Donation O $ ________

Checks payable to: MASSPAC and mailed to address noted below. Purchase orders are accepted from district PACs.

Credit card payments accepted via internet at www.PayPal.com Email recipient: info@masspac.org.

Thank you for your support!