MEMBERSHIP APPLICATION

IDEA Illinois Drug Education Alliance 2800 Montvale Drive Springfield, IL 62704 Phone: 800/252-8951 Annual Membership Dues $35 Youth $45 Adult Additional Donations $________ Annual IDEA Conference Registration free includes membership dues Today's Date: ____/____/____ RENEWAL? Yes No

Name:_______________________________________________________________________________ Address:_____________________ City:______________ County:___________ State:______ Zip:______ E-Mail Address:_________________ Home Telepone: (____)_________ Office Telepone:(____)_________ Mail to: ILLINOIS DRUG EDUCATION ALLIANCE - 2800 Montvale Drive, Springfield, IL 62704 IDEA is a 501 (c) not-for-profit, tax exempt organization