Membership Application

Join the caregivers of Polk, Highlands & Hardee Counties — $30 per family, per year, membership year runs february 1 – january 31.

Applicant

First name *

Last name *

Phone *

Email *

Applicant #2 (optional — same household)

First name

Last name

Cell phone

Street address *

City *

State *

ZIP code *

We are… (check any that fit)

Foster caregiver Adoptive family Relative caregiver Non-relative caregiver Friend of TLC

Anything you'd like us to know? (optional)

Dues can be paid at any monthly meeting or by mail — online card payment is coming soon.