MEMBERSHIP APPLICATION - Home School Legal Defense …

MEMBERSHIP APPLICATION

1 YOUR INFORMATION:

5 Mr. 5 Mrs. 5 Miss 5 Ms. 5 Other title:

First:

Middle initial:

Last:

Suffix:

Marital status: 5 Married 5 Single 5 Widowed 5 Divorced

3 PLEASE SELECT A MEMBERSHIP:

Monthly Auto-pay $12/month

Payments charge on or around monthly membership anniversary; see terms and conditions on back for details

Lifetime $1,200

Best deal!

One-time payment--never needs to be renewed

Address:

STREET

CITY

Email address:

STATE

ZIP

Phone number:

SPOUSE INFORMATION:

5 Mr. 5 Mrs. 5 Miss 5 Ms. 5 Other title:

First:

Middle initial:

Last:

Suffix:

Annual Auto-renew $125/year

Save time and money--renews automatically after 12 months! See terms and conditions on back for details

Annual $130/year

Needs to be manually renewed after 12 months

Annual Auto-renew Group $110/year

Renews automatically after 12 months; see terms and conditions on back for details

Annual Group $115/year

Needs to be manually renewed after 12 months

You must supply your HSLDA Group information to be eligible.

Group number:

2 PLEASE ANSWER:

Have you previously been a member of HSLDA? 5 Yes 5 No

If yes, provide account number:

Is your family facing a legal situation that you want HSLDA to help resolve (e.g., an investigation, a court proceeding, or a contact from

a school or government official)? 5 Yes 5 No

If yes, please explain. HSLDA does not provide legal representation in matters of child custody or domestic disputes between parents.

Group name: ________________________________________ Please see membership for additional qualifying groups.

Subtotal: $

I want to donate to the Homeschool Freedom Fund* $ Make this a monthly donation.

Total: $

*See donate If you have a situation that requires expedited service, please apply for a rushed membership at membership.

4 PLEASE SIGN: Please read the terms and conditions of your membership on the back of this form.

By signing this application, I agree to the terms and conditions. All information presented on this form is true and accurate to the best of my knowledge.

X ____________________________________________________________________ DATE: _______________________________________

5 CHOOSE METHOD OF PAYMENT (PLEASE DO NOT SEND CASH):

5 Check 5 Money order

(Check or money order may not be used

5 Visa 5 MasterCard 5 American Express 5 Discover

for monthly auto-pay or annual auto-renew.)

Card #: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Exp. date: __ __ / __ __

5 Direct debit (Please provide a voided check

so we may process your payment.)

CVV: __ __ __ Signature: _____________________________________________

Send your application and payment to: HSLDA ? P.O. Box 3000 ? Purcellville, VA 20134 We cannot accept faxed or scanned applications. Questions? Call 540-338-5600 or email applications@

M7 7/21

OFFICE USE ONLY

ACCOUNT #

PAYMENT TYPE, DATE, AND AMOUNT

ACCEPTED BY

GROUP #

1

TERMS AND CONDITIONS

Please keep a copy of this page for your personal records.

PAYMENT AUTHORIZATION AND INFORMATION STORAGE

? I authorize HSLDA to charge my indicated form of payment immediately.

? If choosing monthly auto-pay or annual auto-renew, I will provide a voided check or credit/debit card information and authorize HSLDA to set up automatic payments using the payment method provided.

? HSLDA will securely store my payment information. In addition to being used for recurring payments if applicable, this information may be available for payment for other HSLDA goods and services. HSLDA will never charge my stored form of payment without authorization.

Monthly Auto-pay

If choosing monthly auto-pay, I agree:

? To have HSLDA automatically collect payment via direct debit or credit/debit card.

? Payments can only be made by direct debit or by credit/ debit card.

? All regular monthly payments will process on the same day of the month as my membership approval date. If my payment is set to process on a day that does not exist in a month (e.g. the 31st of February), HSLDA will process my payment on the last day of that particular month.

? I will be unable to request cancellation of my membership until 12 monthly billing cycles have completed, unless I stop privately homeschooling.

? HSLDA will auto-renew my membership every 12 months until I cancel.

? Payment updates must be received by HSLDA a minimum of 1 week before my scheduled billing date and must include my HSLDA member number.

? To cancel my membership, I will contact HSLDA to request cancellation and include my name and member number in any such communication. I must contact HSLDA at least 1 week before my scheduled monthly payment to guarantee that payment is stopped. HSLDA is not obligated to refund my payment if I have not followed this cancellation procedure.

Annual Auto-renew

If choosing annual auto-renew, I agree:

? To have HSLDA automatically collect payment on or about my membership anniversary each year.

? Payments can only be made by direct debit or by credit/ debit card.

? Payment updates must be received by HSLDA a minimum of 1 week before my scheduled billing date and must include my HSLDA member number.

? HSLDA will auto-renew my membership each year.

? To cancel my membership, I will contact HSLDA to request cancellation and include my name and member number in any such communication. I must contact HSLDA at least 1 week before my scheduled payment to guarantee that payment is stopped. HSLDA is not obligated to refund my payment if I have not followed this cancellation procedure.

? If a membership discount is added to or removed from my member account during my membership year, I will be charged the appropriate discounted or non-discounted amount when my membership is renewed for the following year.

? Promotional pricing is not available with annual auto-renew.

? Annual auto-renew is not available for Lifetime Memberships.

? Membership discounts and promotional pricing are not available with monthly auto-pay.

? Monthly auto-pay is not available for Lifetime Memberships.

ABOUT MY MEMBERSHIP

LEGAL REPRESENTATION

? I may cancel my membership up to 1 week after membership activation or renewal and receive a full refund of my membership dues. My cancellation request must include my name and application ID or member number. HSLDA does not guarantee a refund if I cancel my membership after 1 week.

? Rush fees are nonrefundable.

? The processing of applications generally takes 3 weeks-- longer during HSLDA's busy season.

? My membership is valid from the date my application is approved.

? I agree to contact HSLDA promptly about any threatened or legal action regarding my homeschool.

? For as long as HSLDA continues to advocate for homeschooling, HSLDA will provide services to my family for the duration of my membership.

? HSLDA is not an insurance company and cannot guarantee representation in every situation.

? In keeping with HSLDA's purpose, legal assistance to protect and advance the right to homeschool is available only if I am the parent, guardian, or legal custodian of a child being taught at home.

? I will receive membership cards after my application is approved.

? Membership dues are not tax-deductible.

? My membership includes a free subscription to the Home School Court Report.

? HSLDA reserves the right to reject a membership application and the right to revoke membership if any information has been misrepresented.

? If my application cannot be approved, HSLDA will refund my membership dues.

? Membership services are not available in connection with any child who receives the majority of instruction through, or is enrolled full-time in, a public school or governmentsupported program based in the home, such as a charter school, virtual charter school, or independent study program.

? HSLDA does not provide legal representation for members in matters involving divorce, child custody, or related domestic disputes.

HSLDA reserves the right to change these terms at any time.

? Membership is not transferable.

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You must sign on the front of this form to indicate that you have read and agree to the terms and conditions. TC 2

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