Becoming a member of ELIJA will give you the following benefits ________ I wish to be a family member $100.00 _______ I wish to be an agency member $500.00 Total Amount Enclosed: $_________
*** Subscription to our newsletter which will include updated information on past and future events (1 per household)
*** Receive special discounted prices to ELIJA WORKSHOPS & EVENTS and never pay late registration fees.
*** Access to The Elija House Autism Resource Library in Levittown
Know that your membership helps ELIJA continue to grow and pursue their mission to EDUCATE THE EDUCATORS and ultimately "Empower Long Island's Journey Through Autism".
Check which applies:
_______ I wish to be an individual member $50.00
Individual Name as I wish to have it appear on the card:____________________________
(valid for member plus 2 individuals)
Family Name as I wish to have it appear on the card:___________________________
(valid only for those whose names are submitted by their agency)
Agency Name as I wish to have it appear on the card:___________________________
Agency must send a list of those who will be utilizing the membership
*Those with Family or Agency Memberships, must have payment for workshops payed by the Name listed on the card
PRINT CLEARLY PLEASE
* Date: ___________ (* Expiring on the 1st of the month you applied the following year. )
Name:_________________________________________________
Address:______________________________________________
City,State & Zip:_____________________________________
Phone Number:_________________________________________
Email Address:________________________________________
Affiliation to the field:_____________________________
Send a Check or Money order with this COMPLETED Form to
THE ELIJA FOUNDATION
665 Newbridge Road
Levittown New York, NY 11756
Thank you again for your support.