Membership Application

*If you would like this information listed on the membership page to be accessible
to other parents or caregivers please check the specific boxes below.

* These Fields Are Required

*The following information will allow us to serve our members better-please check box
most appropriate (This information will NOT be listed on the membership page):

Age of Member

1 to 24     25 to 34     35 to 44     45 to 54     55 to 64     65+    

Classification

 Parent / Relative*  Self Advocate  Professional In-field  Caring Citizen

*If parent of person with developmental or cognitive delay; age of person:

I would like to work with The Arc on (check any that apply):

 Membership  Organizational Issues  Prevention  Public Awareness
 Education  Governmental Affairs  Inclusion  Fund Raising
 Research  Assistive Technology  Other: