WPFC Membership Form

For membership, please fill in the following form, select 'Send Method' and click 'Continue'.

Date:

Name:

Address:

City:

State:     Zip:

Daytime Phone:

Evening Phone:

Fax Number:

E-Mail Address:

I became aware of WPFC through:
    a friend
    a board, faculty, or staff member of WPFC (specify below)
    the website
    university or other educational institute (specify below)
    other (specify below)


I Work in:
    the mental health field (specify below)
    a family owned business (specify below)
    the medical field (specify below)
    an educational institute (specify below)
    other (specify below)


Select Send Method:
    Print this form & Mail along with Check for at least $50.00
    Online via Paypal - Donation Amount

Additional Comments:


Please type the text you see in the image

United Way's Contributor's Choice
United Way funding is a valued source of income to WPFC.

Ask your employer for a Contributor’s Choice Pledge Form (see the sample). Call the United Way at (412) 457-6877 to request one if your employer does not have the form.

Fill in the Contributor Information and Method of Payment sections. To make sure WPFC receives your pledge, list our full name and our Code Number 2159 under the Distribution section (see sample).

Thank you for making it possible to continue our work.

Western Pennsylvania Family Center
733 North Highland Avenue
Pittsburgh, PA 15206
P-412.362.2295 | F-412.363.2489
INFO@WPFC.NET

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