NAMI Wakulla Membership Application

Applicant Information Last Name:
First Name:
Street Address:
Mailing Address, if different:
Home Phone:
Cell Phone:
E-mail Address:

Please let us know if you would be interested in any of the following
Volunteering: Yes No
Fundraising: Yes No
Clerical Work: Yes No
Helping with Outreach: Yes No
Serving on Committee: Yes No
Serving as a Board Member: Yes No

Member Information Member Type:
Individual Family Consumer * Corporate
*Open door memberships are available to consumers and members with limited resources.

Individual Membership Dues	Open Door Membership Dues	Professional Membership Dues	Corporate Membership Dues
$35.00/year	$3.00/meeting	$50.00/year	$350.00/year

Additional Comments or Questions

Contact Information

NAMI Wakulla is a non-profit 501(C)(3) organization, #CH34706. A copy of the official registration and financial information may be obtained from the Department of Consumer Services by calling toll-free (800-435-7352) within the state. Registration does not imply endorsement, approval or recommendation by the state.

You may submit this application, by clicking the "Submit" button at the bottom of this screen. Please print a copy of this applicaton, include it with your payment and mail both to the address below. Thank you for your support.

Make Checks payable to:

NAMI Wakulla

Mailing Address:

2140-C Crawfordville Highway
Post Office Box 458
Crawfordville, FL 32327

Phone:

850-926-1033

Date Dues Paid:

Membership expires one year after payment of dues.