Application form for membership of NIDA 2006

Name

Address

Post Code

Telephone

Date

* I am joining as a:

Parent

Teacher

Psychologist

Other Professional

Dyslexic Adult

Please circle as appropriate.

* If you are joining as a parent, the following information would be helpful:

My dyslexic children:

Date of Birth

Male / Female?

Male / Female?

Male / Female?

* If you are joining as a teacher, please indicate age range(s) taught:

* Other professionals: please indicate area of interest / work:

All information will be treated in the strictest confidence.

Cheques should be made payable to NIDA and sent with this form to:

REGISTERED CHARITY NO.264172