Membership Registration

Please fill out the online form to become a member. If you have chosen to become a member on one of our program registration forms, you do not need to submit this form.

Full Name*:

Organization / Institution / Business:

Street Address*:

Unit:

City*:

Province*:

Postal Code*:

Home phone:

Business phone:

Daytime phone:

Email*:

* required

Chapter:
 North Peel Mississauga

Payment information
Please note there is a fee for membership. Please select your class of membership:
 Family: $50/year Professional / Practice: $75/year Organization / Institution / Business: $125/year Student: $20/year
(Student class is only for currently-enrolled post-secondary students, and members are required to provide proof of enrollment)

Membership fees are non-refundable and non-transferable. Payment can be made by either cash, cheque, Visa or MasterCard, but payment cannot be made online. LDA staff will be in contact regarding payment. Cheques can be made payable to the Learning Disabilities Association of your choice. A $25 service charge will be levied on NSF cheques.
I accept.

I acknowledge that the enclosed information is correct, and by submitting this form I wish to become of a member of the Learning Disabilities Association. Should any information change, I will promptly contact the nearest LDA office to provide an update.
I accept.

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