Membership / Donation Form

Name: (please print legibly)

 

 Please check one: 
Check box image Parent of LS child 
(Parents: please complete
additional form below.)
Check box image Educator or Social Service Professional 
Check box image Organization/Agency 
Check box image Relative/Friend 
Check box image Medical/Scientific Professional 
Check box image Other: (please specify below)		 Contribution level:
Check box image $15 Member 
Check box image $25 Contributor 
Check box image $50 Sustainer 
Check box image $100 Sponsor 
Check box image $250 Friend 
Check box image $500 Patron 
Check box image $1,000 Benefactor 
Check box image Other: $                       
Check box image I am the parent of a child with LS and would like to join but cannot afford any dues at this time 
Check box image Residential agency with client who has LS (free membership)

Street:

 

City:

 

State:

 

Zip Code:

 

Country:

 

Telephone Number:

 

E-mail address:

 

Memorial or Special Occasion Gift This donation is being given in memory of in honor of: 

Send acknowledgement to:
 

Payment Method Total amount: $____________ (U.S. dollars only; do not send cash)

Check box image Check     Check box image Money Order (please make check or money order payable to LSA)

Check box image Visa         Check box image MasterCard 
Credit Card Account Number:

                               

Expiration date:

         

Authorizing signature:_______________________________________________________

Check box image On-line Donation using ECHO.   Go to:  https://www.merchantamerica.com/lsa/echopay.
LSA receipt & public acknowledgement policy A receipt will be sent for all donations of $100 or more, or upon request. The names and states (or countries) of all donors of $30 or more will be printed in our newsletter, unless otherwise requested.  Special occasion and memorial gifts will be printed in the newsletter with no gift amounts given.
Send to: Lowe Syndrome Association, 18919 Voss Road, Dallas, TX 75287. The IRS recognizes the LSA as a Section 501(c)(3) non-profit charitable organization. All donations are tax-deductible to the extent provided by law.