MEMBERSHIP APPLICATION
2001

Date:_________ TELEPHONE:
Office ( )______________
Home ( )______________
Name:____________________________ FAX
E-Mail
Address:

City: State: Zip Code:

MEMBERSHIP OPTIONS:

_______ lifetime Member $l,000.00

_______Founding Member 500.00

_______Charter Member 100.00

_______Family Membership 50.00

_______Individual Membership 25.00

_______Student Membership 15.00

PROFESSIONAL MEMBERS TO BE ON OUR REFERRAL LIST OF THERAPISTS $100.00

MONTHLY DONATIONS:

MASA is in need of residual income to cover overhead and educational programs.
No amount is too small to give on a monthly basis. Ongoing costs such as postage
to send out educational materials, telephone counseling, copying and supplies are always fixed expenses. We need your help to provide these services. All donations are tax exempt. Our Federal ID number is 95-4364494 and we are a 501©3
Organizations. Checks should me made to MASA, P.O. Box 2966, Huntersville,
NC 28070 or to 8023 Maxwellton Dr., Huntersville, NC 28078.

EVERY PERSON MUST BECOME A VOICE FOR THE CHILDREN