New Members Updated New Membership Application Online New Membership Application Last Name* Husband's First Name* If applicableWife's First Name* If applicableAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Ohio County Home PhoneCell PhoneEmail* Enter Email Confirm Email Add me to CHEO's E-mail list* Yes No Are you a Support Group Leader* Yes No Are you a member of HSLDA? Yes No Today's Date MM slash DD slash YYYY mm/dd/yyyyMembership Kit Needed?*Do you need a full Membership Kit mailed to you? If you answer YES, then you will receive your Membership Kit and your membership card. If you answer NO, then you will just receive your membership card. YES NO CHEO New Membership* One Year Membership = $30.00 Two Year Membership = $50.00 Five Year Membership = $115.00 Notice: This box will be left blank. Message under the box. CHEO does not store your credit card number.Credit Card* MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name Δ
