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	Greater Hartford
	Literacy Council
	One Union Place
	Hartford, CT 06103

	(860) 522- 7323 or (860) 522- READ

Organization/Business Membership Form

Click here to download a printable version of this form.

We welcome your participation! The fee structure for organization/business membership is designed to be as inclusive and affordable as possible. We encourage municipal governments, school systems, and other large organizations/businesses to join for an annual fee of $100. For this amount, one program/school/department is considered a member and the other programs/schools/departments they operate or fund can join for just $25 each.

Please select the appropriate membership fee category below and mail this completed form along with your check made payable to: Greater Hartford Literacy Council. Your membership will become effective when payment is received. The duration of membership is twelve months and is renewable. Thank you for your support!

To help support Literacy Council projects such as our Books at Home initiative, we welcome your contribution in addition to the membership amount. (A contribution of $36 will provide a child with a new book each month for one year. A $1,000 contribution provides books for an entire classroom for a year.)

Membership Fee Categories: Annual Dues

Organizations with an annual budget more than $500,000 $100

Organizations with an annual budget less than $500,000 $50

A school, program, or department funded/operated by a member town, city, school system, large organization or business* $25

City of Hartford programs and schools** $0

* If a town, city, school system, large organization, or business pays a $100 membership fee, the programs/schools/departments it funds/operates may join for $25 each. (One of the programs/schools/departments will be exempt from the fee, but must complete this form.)

** Because the City of Hartford is a major sponsor of the Literacy Council, programs and schools funded/operated by the City of Hartford are exempt from the fee, but must complete this form.

Today's Date:

September 7, 2008

Organization:

Address:

City:

State:

Zip:

Non profit organization?

Yes No

Organization's website

If you wish to have a link from our website to yours

Contact Person

Title

Phone:

Fax:

E-mail:

By providing your e-mail address, you will receive our monthly e-newsletter, periodic advocacy alerts, and other updates.

1) Briefly Describe the nature of your organization, department, or business (150 words or less):

2) Which population does your organization primarily serve?

Children	Youth		Adults	Families
(Birth-grade 6)	(Grades 7-12, ages 13-17)	(18-25)	(25+)
Other, please describe

3) Does your organization provide literacy services? Yes No
If yes, which type of literacy services do you offer? (please check all that apply)

Pre-school After School Program Reading Instruction Vocational School Financial Literacy	K-12 Instruction ESL/ESOL ABE Higher Education Health Literacy	Tutoring/Mentoring High School Completion (GED,EDP) Citizenship Workforce/Vocational Literacy Other, please describe