Georgia Association of the Deaf

Membership Application

First Name:__________________________ Last Name:__________________________

Address:_______________________________________________________________

City:__________________________ State: __________ Zip Code: ________________

Date of Birth: ____________________ Phone: (____) ________________ TDD/Voice

E-Mail: _______________________________________ Fax:____________________

Local Chapter preferred: __________________________________________________

Circle which applies to you:     Male / Female               Deaf / Hard of Hearing / Hearing

Please check one: Membership:    (   ) Renewal                    (   ) New

Regular: check one:                         (   ) $15.00 / year          (   ) $30.00 / 2 years

Senior Citizen (55 and up):             (   ) $13.00 / year          (   ) $26.00 / 2 years

High School Student:                       (   ) FREE!!

(Teacher signature required)

Print or copy this page and mail with your check to:

        GAD

        P O Box 1616

        Stockbridge, GA 30281-1616