Start by determining your membership type and dues:

• Agency Membership - $375.00
  For individuals working at provider agency.
• Individual Service Recipient or Family Member of Service Recipient - $50.00
  For individuals receiving service or family member(s).
• Professional or Consultant - $150.00
  For People NOT affiliated with a provider agency.

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* indicates required fields

New Membership*        Renewing Membership*

Your Name: *

Agency Name: *

Agency Contact People (if different):

Street Address 1: *

Street Address 2:

City: *

State: *    Zip Code: *

Daytime Phone: *

Fax:

Email: *

Website:

Vendoring Regional Center(s):

(For Agency Membership Only) Total number of people served: SLS    ILS

Geographic Coverage (Counties):

Services your organization provides (check all that apply):
ILS   SLS   Other:

Your Membership Type (select one) Agency Membership - $375.00 Individual Service Recipient or Family Member of Service Recipient - $50.00 Professional or Consultant - $150.00  *

For the time being, PayPal is not available for member payments. Our new system will soon be up and running for a much smoother online member management and payment process. For now, you'll have to print this page and mail it with a check.

Send checks to:
Rebecca Burkhardt, CSLN Membership Chair
15501 San Fernando Mission Blvd.
P.O. Box 9604
Mission Hills, CA 91346-9604

For additional membership information, contact - 818-361-6400 X 122