Membership Application

If you are interested in joining our organizations, please fill out the following form.

First Name:
Last Name:
Address:
City:
State:
Zip Code:
Home Phone: - -
Work Phone: - -
Your Email:

Are you the relative of a developmentally disabled person?
Yes
No

If yes, what is the relationship to you?      
If you are a parent or guardian, in what kind of program
is your son or daughter currently enrolled?		      

What type of membership is this?
New Membership
Renewal Membership

I would like to be involved in the following functions (check all that apply):
Education
       
Recreation Activites
       
Aid Red Hot Activities
       
Public Relations/Media
       
Leadership
       
Residential Monitoring
       
Membership Development
       
Governmental Affairs
       
Fund Raising
       
Other
       

Membership Dues

Membership dues (for State, Local, and National) are $20 per year.
The membership year is March thru February. Your inital dues will be prorated monthly thru February.

Make checks payable to Sarpy/ARC.

Mail Checks to:
Doreen Brannian
Membership Chairman
3222 Chad Street
Bellevue, NE 68123

For further information please call, (402) 291-8494

Your membership dues are income tax deductable!