MMHTF Annual Paid Membership Form

Milwaukee Mental Health Task Force Annual Membership
SubmitDate*

MonthDayYear
Date
MemberName
Do you have a Payment Code for a previously submitted membership form?

YesNo
PaymentMethod
Membership Type*

Individual/ Community MemberAgency/ Organization
Email*
Enter your email address. You will receive an email confirmation with your completed Membership Form and/or payment confirmation.
Enter your Payment Code
e.g. M22999
Name of Member (Individual or Organization) this payment is for
Amount of Payment
Enter the amount listed on the Membership form that was already submitted.
Future Online Payment Message 1
Future Online Payment Message 2
Future Online Payment Message 3
Future Online Payment Message 4

Member Information
Name*

First NameLast Name
Organization Name
Phone
Enter your phone number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Suggested contributions for organizations with budgets of:

$5,000 - $300,000 – pay $100 annual membership$301,000 - $750,000 – pay $250 annual membershipAbove $750,000 – pay $500 annual membershipWe encourage any organization that can pay a $1000 annual membership to do soOther/custom amount
Community members are warmly invited to join:

Community member – active in task force. All contributions gratefully accepted.Community supporter – not active with the task force, but supportive of its efforts. All contributions are gratefully accepted.
Amount of Contribution*
If this membership is for an organization, please see suggested amounts above
Method of Payment*
How do you plan to pay later?

Submit Form
Note: Online payments will appear on your statement as paid to "DRW". Disability Rights Wisconsin (DRW) is the fiscal agent for the Milwaukee Mental Health Task Force.
Calculated amount
Total Payment Amount

prevnext( X )
USDTotal payment

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Milwaukee Mental Health Task Force Annual Membership