Name: _______________________________________________________

Title: _______________________________________________________

Organization: __________________________________________________________

Address: __________________________________________________________

__________________________________________________________

Telephone: ______________________________

Fax: ______________________________

E-mail address:______________________________

Are you interested in becoming a JJC trustee? Yes ___ No ___

May we include your information in a JJC member list that we post on our website? Yes ___ No ___

If you would like to add your organization's website to the links page of the Juvenile Justice Coalition website, please indicate your website address ______________________

Youth/student ($15 annual dues) __

Individual ($40 annual dues) __

Family ($50 annual dues) __

Organization ($100 annual dues) __

In addition to my/our membership, I/we wish to donate __________

to support JJC (your donation is tax deductible)

Return form with check or money order payable to JJC (tax ID #34-1754680) to:

JJC

P.O. Box 477

Bath, OH 44210-0477