ACHIEVA RESOURCES MEMBERSHIP FORM
Thank you for becoming a member of Achieva Resources Corporation Inc. We welcome you as a partner in meeting our goals to serve challenged consumers and their families.

Name: ________________________________________________________

Address:_______________________________________________________

______________________________________________________________

______________________________________________________________

Home Phone:_______________________

Work Phone:_______________________

Email:_____________________________

Single ($20) Family ($30)
Consumer Club ($2)
Executive VP Club ($50)
President's Club ($100)
Director's Club ($250)
Endowment Club ($500)

My age group is: 1-24 25-34 35-44 45-54 55-64 66+

My interest in Achieva Resources is:
Self-Advocate
Interested Citizen
Human Service Professional
Medical Professional
Educational Professional
Parent/Relative of Consumer

If a parent, your child’s age is:
1-21
22-35
36-50
50+

_________ I need information on how to receive services from Achieva Resources

_________ I would like information on being a volunteer at Achieva Resources

Please mail to: Achieva Resources, P.O. Box 1252 Richmond, IN 47375
Make checks payable to: Achieva Resources
Any questions please call us at: 765-966-0502