TAHIC Membership Application

Print this application form and mail to address below

Mailing Address
     TAHIC does not release any mailing list information.

   Name __________________________________________________________

   Address _______________________________________________________
    
   City ____________________________ State _____ Zip _____________

   Phone (   ) _______-_________  Voice / TTY / Both (circle one)


Type of Membership
  [__] $8 - individual  [__] $10 - family  [__] $25 - contributing

  [__] $50 - sustaining  [__] $100 - patron


Please check all that apply
I am a:

 [__] parent of a hearing impaired child or _______ children.

      If so, please list name, age, and school: ____________

      ______________________________________________________

 [__] teacher at ___________________________________________

 [__] interpreter at _______________________________________

 [__] speech therapist at __________________________________

 [__] audiologist at _______________________________________

 [__] friend     [__] other ________________________________


Mail to:   TAHIC
           1821 Old Donation Parkway, Suite 10
           Virginia Beach, Va. 23454