|
MENTAL HEALTH AMERICA |
|
of HENDRICKS COUNTY |
 |
75 Queensway Dr - Suite A, Avon, Indiana 46123 Phone: 317-272-0027 |
|
MEMBERSHIP FORM
YOUR MEMBERSHIP, GIFT OR MEMORIAL
To the Mental Health America of Hendricks County
"Working for Hendricks County’s Mental Health and a Victory over Mental Illness"
|
MEMBERSHIPS |
_____ Corporate Bell $500 _____ Bronze Bell $25 _____ Gold Bell $100 _____ Associate Bell $15 _____ Silver Bell $50 _____ Other $ ____ _____ New Member _____ Renewal SPECIAL GIFT $____________ (does not include membership)
Contributions are tax deductible
| Name: ___________________________________________ |
| Address: _________________________________________ |
| City: ___________________ |
| State: ________ |
| Zip Code: ____________ |
| Telephone Number: (___)____________ |
MEMORIAL $_____________________
ACKNOWLEDGEMENT SENT TO:
| Name: ___________________________________________ |
| Address: _________________________________________ |
| City: ___________________ |
| State: ________ |
| Zip Code: ____________ |
| Telephone Number: (___)____________ |
| (In Memory of) ___________________________________________________________________ |
______ I would like to learn more about volunteer opportunities available through MHAHC
Hendricks County Mental Health America is not tax supported. Programs and service funding is provided by United Way of Central Indiana, memberships, gifts, and contributions.
© 2007 Mental Health America of Hendricks County All Rights Reserved