Lakeshore Connection


Membership Registration Form

This form is to be used for mailing your payment to Lakeshore.
To pay your membership fee securely online with your credit card, click here.


Name ___________________________________________________

Title _____________________________________________________

Organization ______________________________________________

Address __________________________________________________

City_____________________________ Zip Code__________________

Phone (_______)____________________________________________

Type of Business ____________________________________________

Email Address ______________________________________________


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To be filled out by the office:

Membership from ________________ to ______________

Method of payment:

Check #____________     Cash $____________
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Annual fee per member: $95.00       Monthly guest fee: $10.00

Please make your check payable to Lakeshore and mail to:

Lakeshore Educational & Counseling Services
5475 Liberty Avenue
Vermilion, OH 44089