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MEMBERSHIP APPLICATION

Please print this page, complete it and mail it to the address below:

Name: ______________________________________________________________

Birth date: ____/_____/_______ (Optional)

Address: ____________________________________________________________

City: ____________________________ State: _________ Zip: ______________

Phone: __________________________ E-mail: ____________________________

Please check all that apply:
( ) Licensed Foster Parent with _______________________________________
( ) Agency Staff with ________________________________________________
( ) Interested Community Member

Please make check or money order payable to FPAWS - 451 SW 10th Street, Suite 103, Renton WA 98055-2981
( ) VISA ( ) MasterCard Card Number: _________________________________________
Expiration Date: __________
Name as it appears on the card: _________________________________

Here's my annual membership dues: ( ) Renewing ( ) New Member
( ) $20.00 Individual membership ( ) $100.00 Tribes, Private Agency, Small Business
( ) $25.00 Family membership ( ) $250.00 Corporation
( ) $30.00 Foster Parent groups

Ethnicity: ( ) African American ( ) Caucasian ( ) Asian/SE Asian
( ) Hispanic/Latino ( ) Native American/Eskimo

I'd like to make a contribution of:
( ) $25.00 toward empowering foster families ( ) $50.00 toward supporting foster families
( ) $100.00 toward advocating for foster families ( ) $_________toward positively impacting foster care

I'd like to make a contribution of $ _________________
In honor of _______________________________
(please list name as you'd like it printed in the newsletter)

For ______________________________________ (graduation, adoption, memorial, etc...)

( ) Check here if you do not want the honoree to be publicly acknowledged in print.

ALL DUES AND CONTRIBUTIONS ARE TAX DEDUCTIBLE TO THE EXTENT COVERED BY LAW  FPAWS Foster Parent Association of Washington State

P.O.Box 1638,Olympia Wa 98501
Telephone: 800.391.2273 Fax: 425.227.9295
E-mail: fpaws@fpaws.org

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