875 NORTHPARK DRIVE, BUILDING 2, SUITE 600
RIDGELAND, MS 39157
Phone: 601-899-5880 Fax: 601-899-5548
REQUEST FOR MEMBERSHIP- DOWNLOAD PDF
NAME: ____________________________________________________________
FACILITY: ___________________________________________________________
ADDRESS: __________________________________________________________
CITY: _________________________ STATE: _______ ZIP CODE: ____________
EMAIL: ____________________________________________________________
Enclosed is my membership fee of (Check one):
_____ $25.00 Individual
_____ $50.00 Supporter
_____ $100.00 Corporate
_____ $250.00 Benefactor
_____ $_____ Other
Please use my gift for the following:
_____ Children & Youth Programs
_____ Parenting Programs
_____ Referral Programs
_____ Training & Community Education
_____ My gift is unrestricted
_____ With my membership, I would be interested in serving on a planning committee to benefit NCADD’s efforts in the community.
THANK YOU FOR YOUR SUPPORT