Lift Disability Network

Membership Application

Your Name: ✎  ❑ Dr.     ❑ Rev. ❑ Pastor ❑ Mr. ❑ Mrs. ❑ Miss ❑ Ms.

Name of Church/Organization (if applicable): ✎ 

Address: ✎

City/State/Zip+4: ✎

Phone: ✎                                                                            Fax: ✎

E-Mail Address: ✎                                                              Church/Organization Website Address: ✎

❑ I have read the CCPD Statement of Faith and agree with it.

❑ I will pray for the ministry of CCPD.

❑ My membership category is:

             ❑ Individual ($50) ❑ Church ($100) ❑ Non-Profit Organization ($100)

             ❑ Contributor ($250) ❑ Benefactor ($500) ❑ Corporation ($1,000)

             ❑ Student ($25) (On reverse, give name & address of school where you are enrolled.)

❑ In addition to my annual dues, I wish to make the following donation:

Amt Enclosed

$

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❑ Please subscribe me to the Journal of Religion, Disability and Health at the

    discounted rate of $48.00 (payment enclosed – standard subscription is $60 annually)

Total Enclosed  
$

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For Individual or Student Members:

Are you presently involved in disability ministry: ❑ Yes ❑ No

             If yes, is your work:

                          ❑ Full-time         ❑ Part-time       ❑ Volunteer

For Church or Organization & Above Members:

On the reverse of this page, please provide complete contact information. List the names, addresses, phone numbers, & e-mail addresses of the 2 additional individuals to whom copies of CCPD News is to be mailed.

(Annual dues include 3 subscriptions.)

For All Members:

Types of disabilities served/ministry offered:

             ❑ Physical Disabilities                               ❑ Cognitive Impairments

             ❑ Deaf/Hard-of-Hearing                            ❑ Blind/Low Vision

             ❑ Environmental Illness                            ❑ Brain Trauma

             ❑ Learning Disabilities                              ❑ Age-Related Disabilities

             ❑ Mental Illness                                        ❑ Chronic Illness

             ❑ Caregivers                                            ❑ Other:

Signature

 Date

Include check payable to: Lift Disability Network

and mail to:

301 E. Pine St. Suite 150

Orlando, FL 32801

If you have a brochure or other publication concerning the ministry you are a part of,

we would love to receive a sample, or to be on your mailing list. Thank you!