Membership Form

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Indiana Association for Infant and Toddler Mental Health, Inc.

I would like my contribution to go towards Membership or Donation.

I would like my contribution to go to the following organization. (Check one below)

	Indiana Association for Infant and Toddler Mental Health, Inc.
Individual Membership Fees
	$30.00 Profesional
	$15.00 Family
	$10.00 Student
	Please send me information on how to also join the WORLD Association for Infant Mental Health.
Group Membership Fees
	$100.00 Option A - includes up to 4 individual memberships.
	$250.00 Option B - includes up to 10 individual memberships.
Individual / Corporate Donations
	$250.00 Bronze
	$500.00 Silver
	$1000.00 Gold
	$2500.00+ Founding
	I wish to make an additional contribution of $_____________.
Please only select one at a time. If you wish to become a member or donate to more than one organization please send this form multiple times. Thank you.
My payment or donation is not included this time because I would like to request additional information on the above organization that I have selected.

Please enter all applicable information below

Your Name
Address
City
State
Zip Code
Phone #
E-mail
Organization
Payment amount
In memory of

Please mail this printed page to the address below.
If you would like to fax this form the number is (317) 638-3540.

Please make checks Payable to
Indiana Association for Infant and Toddler Mental Health

Please mail in Checks to:
IAITMH, 1431 North Delaware Street
Indianapolis, Indiana 46202
Your contribution may be tax deductible!

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