Name _________________________________
Telephone(Home) ______________________ Work_________________
Address _____________________________
School District ________________________________________
City ______________________________
State _____________________________
Zip __________
Local Chapter Affiliation ______________________________


Please check appropriate area(s):

__Parent of LD individual __LD adult __College Student __Educator (Specify)_________ __Other (Specify)________

INTERESTS __Advocacy __Education __Fundraising __Conference __Newsletter __Serving a Local Chapter

____Enclosed are annual dues
of $30.00 (includes national,
state & local organizations)
____Enclosed is an additional
contribution of $_______

Please make checks payable and mail to:
LDA of Pennsylvania
Box 208, Toomey Bldg.
Uwchland, PA 19480

Membership year begins October 1st. Current members will receive a renewal notice from national LDA before October 1, each year. Dues and contributions maybe be treated as charitable contributions for Federal Income Tax purposes.