Membership Form

"Ring Out Hope" music video order form

	Yes, I would like to order music video(s) for $9.95 each.
	My payment is not included this time because I would like to request additional information on the music video.
	My payment is not included this time, Please bill the address below.

Please enter all applicable information below

Your Name
Address
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Phone #
E-mail
Organization
Payment amount

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
The Mental Health America of Indiana.

Your contribution may be tax deductible!

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Mental Health America of Indiana
1431 North Delaware Street
Indianapolis, IN 46202
(317) 638-3501

1-800-555-MHAI

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