Membership Application

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Membership Options

Individual - $13.00 per yearFamily - $16.00 per year

If choosing a Family Membership, please list the names of all individuals included. (Please note: All family members must be immediate family and live in the household of the primary member).

How did you hear about The Arc of the Wabash Valley?*

Please make checks payable to: The Arc of the Wabash Valley

Checks may be mailed or delivered to:

The Arc of the Wabash Valley

11 Cherry Street

Terre Haute, IN 47807

Electronic Signature & Acceptance

I agree that the use of a key pad, mouse, or other device to write, apply, or affix by copy or pasting or other electronic means, my signature below, constitutes acceptance and agreement as if signed in writing and has the same force and effect as signature affixed by hand.

Acknowledgements:

1) I have read, understand, and agree with the Electronic Signature & Acceptance above.

2) I understand that submission of this application does not constitute a contract or agreement for a board position, employment, or membership with the Arc of Vigo County, Inc. (DBA, Arc of the Wabash Valley) or "The Arc" and that the decision to accept my application and grant a membership is at the sole decision of the Board of Directors. Furthermore, I understand that the Board of Directors may reject my application for membership without obligation of explanation of their reasoning, decision models, etc.

3) I understand that, should I be selected a member of The Arc, my membership will be at will and that I may resign from membership at any time and for any reason and that conversely, the board reserves the right to dismiss my appointment based on violations of State Arc guidelines, Arc of Vigo county agency policy, and/or signed policy agreements including, but not limited to: Code of Conduct, Conflicts of Interest, and Corporate Compliance Policies, agency by-laws, conduct unbecoming a member, violations of law or criminal convictions, or by a vote of the Board of Directors in accordance with its Bylaws and established practices.

The Arc of Vigo County, Inc. is an Equal Employment Opportunity Agency and considers all applicants without regard to race, color, religion, gender, national origin, age, marital status, veteran’s status, the presence of a mental, physical or sensory disability, sexual orientation, or any other legally protected status.

Signature*

Please verify that you are human*