New Member Sign-Up Form

Click HERE to see a list of the benefits of CHADD membership.
CHADD is a national organization with chapters all over the U.S.
Not from West Virginia? Click HERE

The CHADD Success Sign-Up Form
Chapter Affiliation: WV CHADD - #10E

__Yes, I want to succeed with CHADD! __New Member __Renewal Membership

          __$35 Student Membership
          __$45 Family or Educator Membership
          __$110 Professional Membership
          __$300 Organizational Member

Name: ____________________________________________________________

Occupation: _______________________________________________________

Address: __________________________________________________________

City, State Zipcode: ________________________________________________

Phone (day): _______________________________________________________

Phone (evening): ____________________________________________________

Email: ____________________________@________________________________

I am: (check all that apply)
      __ Parent or other family member of a child with ADD
      __ An Adult with ADD
      __ An Educator
      __ A Health Professional

Payment:
__Check __VISA __Mastercard __American Express

Name on card: _______________________________________________

Card Number: ________________________________________________

Expiration Date: ______________________________________________

Signature: ___________________________________________________

Organization (If organizational member): ______________________________________

Print and Mail to:
Lea Burnside, Coordinator
WV CHADD
2697 Villa Nova Ridge Road
Duck, WV 25063

Or, you can FAX this form (with credit card info) to:
(301) 306-7090