| DI Guild Membership Application Form | |||
| Please print this page and when complete send it to the address below. | PLEASE USE BLOCK CAPITALS | ||
| Name: (Mr/Mrs/Miss/Ms/Dr/Other ) | |||
| Address: | |||
| Post Code: | Telephone: | ||
| I am a teacher / psychologist / head teacher / parent / other (please state) | |||
| If a DI trained teacher, please give course LOCATION | |||
| YEAR Completed | and, if applicable, DILP number | ||
I wish to join the Dyslexia Institute Guild. I enclose a cheque
for £39.50 (renewable annually)made payable to the Dyslexia Institute. (Overseas members please add £10 postage) |
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I would like to pay by Direct Debit at a reduced rate of £37 p.a. Please send me the appropriate form. |
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I am currently attending the Dyslexia Institute Postgraduate Diploma
course/ Distance Learning Certificate Course. I enclose a cheque
for £20. |
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| Signed: | Date: | ||
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I wish to pay by mastercard/visa and authorise you to debit my account
for |
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| Card
Number
Expiry Date
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| Please return to Lesley Freedman, THE DYSLEXIA INSTITUTE, 2 Grosvenor Gardens, London, SW1W 0DH | |||
| Tel: 0207 730 9202 Fax: 0207 730 0273 e-mail: guild@dyslexia-inst.org.uk Website: www.dyslexia-inst.org.uk | |||