LLLI Medical Associates
Membership Information Form
Membership Information
Membership in the Medical Associates Program is $150 for one year. Please print out and mail this form with your payment to:
La Leche League International Medical Associates Program
957 N. Plum Grove Road
Schaumburg, IL 60173 USA
___ Enclosed is my $150 check or money order payable to LLLI Medical Associates Program.
___ Charge my payment: __MasterCard __Visa __American Express __Discover
Account Number _________________________________________
Exp. Date ____________________ 3 or 4 digit Security Code _____________
Signature: __________________________________________
Name (Please print ) __________________________________________
Professional credentials __________________________________________
Field of practice __________________________________________
Email Address __________________________________________
Web site __________________________________________
Telephone __________________________________________
Send Medical Associates Materials to: ____ Home office ___ Business office
Name of Business if applicable __________________________________________
Address __________________________________________
City __________________________________________
State/Province/Country __________________________________________
Zip/Postal Code __________________________________________
___ I would like my name listed on the LLLI Web site in the Leader-only section. The contact information above will be listed unless you specify any changes below.
___ I would like to answer questions for the Medical Associate column in Leaven.
(Web page registration)
