Yes! Please include me in the membership of the Florida Chapter of the American Horticultural Therapy Association, Inc.

Date: ________________

Name: _______________________

Address: ___________________________________________________

___________________________________________________________

City: ________________________  State: ___________ Zip: _________

Daytime Phone: ________________

Evening Phone: _________________

E-mail Address: _________________

Membership Category:

______ Individual  $25

______ Full Time Student  $10

______ Organization  $45

______ I do not wish to become a member, but here is my donation to further Horticultural therapy.

Amount enclosed: $___________

Please make checks payable to FAHTA

You may print and mail this form along with your check to:

Connie Roy-Fisher
381 Tequestra Drive
Tequestra, Fl 33469