For your membership (new or renewal) and your general or memorial donation, please complete and submit the following form. We will then contact you for confirmation. We sincerely appreciate your support and involvement.
First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail
Select any of the following options that apply:
(Note: the membership is for the calendar year and
runs from January 1st to December 31st)
Individual Membership: $15.00/year
Couple Membership: $25.00/year
General Donation
Memorial Donation
If you are making a General Donation, how much do you wish to contribute?
If you are making a Memorial Donation, how much do you wish to contribute?
If this is a Memorial Donation, please enter the name of the Deceased:
If this is a Memorial Donation, please enter the name and address of the Next of Kin or Administrator:
Comments or suggestions ... ?
If you are a Polio survivor, please enter the year that you had Polio:
