mberform

Name_____________________________________________________
Address___________________________________________________
City_________________________________ State________
Zip Code + 4 Digit ________________________
Telephone# ____________________________
Email Address __________________________

Please Check One:
Parent______ Guardian______ Grandparent_____
Individual with Spina Bifida_______ Professional__________
Other (Please Specify)_______________

Child Information:
Name_______________________________________________
Birth Date____________________________________

____ Membership $10.00 (Local Level Only)
____ Membership $30.00 (Local $10.00 and National $20.00)
____ Professional $50.00
____ Patron $100.00
____ I am unable to pay at this time, but wish to receive the local newsletter.
____ I would like to sponsor member(s)
____ I would like to be contacted by another parent
____ I would like to be contacted by an adult with Spina Bifida.
____ I would like to be a volunteer.
Can we include your information in a local Membership Directory?
____ Yes ____ No

Together, We can make a difference!

Make checks payable to:
SBAMN

Mail to:
Spina Bifida Association of Minnesota, Inc.
P.O. Box 29323
Brooklyn Center, MN 55429
651-222-6395

Spina Bifida Association

of Minnesota

SPINA BIFIDA ASSOCIATION OF MINNESOTA

Membership Form

2008

Membership Dues

Together, We can make a difference!