National Alliance on Mental Illness
page printed from NAMI Forsyth Dawson Lumpkin
NAMI FDL MEMBERSHIP FORM (To print and fill out)
Membership is good for one year. I wish to join or renew (please check one):
___ $35.00 Individual or Family Dues
___ $3.00 Open Door Dues
For families or individuals with limited incomes.
Date: _________________
Name: _______________________________________________________
Address: _____________________________________________________
City, State and Zip: _____________________________________________
Telephone: _______________ E-Mail: ______________________________
I wish to make a cash donation to NAMI FDL:
____ $25 ____ $100 $________(Other) Donation (tax deductible)
$_______ Donation “In Memory of”: ___________________________
$_______ Donation "In Honor of": _____________________________
TOTAL ENCLOSED: $_______________ Membership / Donation
Make checks payable to “NAMI FDL”. Bring to our next Thurs. meeting or mail to:
NAMI Forsyth Dawson Lumpkin
P.O. Box 2665
Cumming, GA 30028