Mail Membership Form
Fill in Form and Print
Mail to: Michigan Dyslexia Institute, 532 E. ShiawasseeSt., Lansing, Michigan 48912
Back
Name Date:
Street: City:
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Phone: (include area code) Work Phone:
Email:
Select Membership Level: Individual $35 Student $25 Family $50 Contributing $50 Organizational $60 Sponsor $100 Funding $250 Sustaining $500 Benefactor $750 Patron $1000
Method of Payment: Check Visa Mastercard
For Credit Card: Name On Card:
Credit Card Number: Expiration Date: (mm/yy)