Please provide the following contact information:

Name
Street Address
City
State/Province
Zip/Postal Code
Country
Home Phone
E-mail
	# of Annual Membership(s) at $5.00 per person
	# of Lifetime Membership(s) at $100.00 per person

Please provide the contact information for additional memberships:

Name
Street Address
City
State/Province
Zip/Postal Code
Country
Home Phone

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
	Print form and mail with check to:   The Arc of Delaware County 34570 State Highway 10 Walton, New York 13856
	For questions regarding membership or to pay with  Credit Card, call (607) 865-7126 or e-mail Community Relations.