PLAN Membership Form for Individual Parent/Guardian or Ally

Name:

Address:

City/state/zip:  

Tel:

Cell:

Fax:

Email:

Organization or School you are part of (if any):

I am a: (Please check the one that best describes you)

Parent/guardian

Staff person working with parents/guardians

Community member

Other:

S
M
L
XL

If you are a parent/guardian, how many children do you have?

What are their ages? (Please check all that apply)

0-5 years old

6-12 years old

13-18 years old

Over 18 years old

The issues I am most concerned with are:
(Please check all that apply)

Child Care Quality/Affordability

Education Equity

Economic Justice

Immigrant Rights

Family Support

Other: