MEMBERSHIP APPLICATION FORM

Yes, I would like to join the Chesapeake-Potomac Spina Bifida

Enclosed is my $25 annual membership fee.

( ) I would like to join, but I am unable to make a donation due to financial hardship

I am a ( ) parent of a child with spina bifida ( ) an adult with spina bifida ( ) a relative ( ) other: _______________

Please make check payable to and mail to:

Chesapeake-Potomac Spina Bifida
P.O. Box 1750
Annapolis, MD 21404

Please check below if you would like to:

( ) Receive more information about CPSB

( ) Become a volunteer

( ) Make a non-monetary donation to CPSB

    Describe:________________________________________________

NAME: ______________________________________________

ADDRESS: ___________________________________________

               ____________________________________________

               ____________________________________________

EMAIL:     ____________________________________________


PHONE: _(_____)________________

For further information, contact the association at 1-888-733-0988.

THANK YOU.

Chesapeake-Potomac Spina Bifida, Inc.
P.O. Box 1750
Annapolis, Maryland 21404
Phone: 1-888-733-0988
Fax: 1-410-295-9744



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