PARENTS AND ASSOCIATES

Parents and Associates of the Northern Virginia Training Center

Membership Application

Parents and Associates, Inc., a 501 (c)(3) agency, was incorporated on May 20, 1983, as a nonprofit organization. Our membership consists of parents and other citizens whose primary purpose is to promote the quality of life of residents of the Northern Virginia Training Center. Parents and Associates plays a key role in assisting the Director and his staff in insuring that operation of the Center effectively supports this purpose. Parents and Associates also supports the families of those with mental retardation and issues for citizens with mental retardation residing in their own homes or in other residential settings in the community.

The dues are $10.00 per person for single membership, $15.00 for family membership, and $25.00 for a participating membership (includes minutes of General and Board meetings). Membership year follows the fiscal year July 1 - June 30. Please check the appropriate line below, fill out your name and address, and send your check payable to Parents and Associates of NVTC to: Membership Chairman, Parents and Associates of NVTC, 9901 Braddock Road, Fairfax, VA 22032-1941. Additional donations are always welcome and very much appreciated.

____Single Membership ($10.00) ____Family Membership ($15.00)

____**Participating Membership ($25.00)______Additional Donation $_______

**Includes minutes of Board & General Membership meetings)

Total Members _______(If other than single membership)

THANK YOU FOR YOUR SUPPORT

Name/Names_____________________________________________________

Address_________________________________________________________

City__________________ State _______Zip___________ - ________

County __________Home Phone (___)__________Work (____)_____________

E-Mail Address _________________________FAX (____)_____________

Please indicate your voting location ____________________________________

(Examples: Robinson High School, Buckhall Fire Department, etc)

Client Residential Information

NVTC Resident’s Name____________________________________ Unit__________________

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Community Client’s Name ______________________________________

Address__________________________________________________________

Group Home Provider/Contractor_________________________________________________

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Your relationship to the above NVTC resident or Community client____________

(Parent, brother, sister, guardian, friend, etc)

____ I would like to volunteer to help P&A of NVTC, please contact me