The Chesapeake-Potomac Spina Bifida is a regional association created to support the needs of individuals with spina bifida and their families.

In order to inform and serve you, please complete the form below. By doing so, you will receive announcements of the association's services.

Information collected will be held in strict confidence and will not be sold or given away.

Thank you for completing this form. We hope the information contained on this site and information you will receive by mail is beneficial and you will consider becoming a member of the association. If so, please go to Membership Information.

* Date ,
* First Name
* Last Name
Title
Organization
Address 1
Address 2
City
State
Zip
* Email
Home Phone
Business Phone
I am a(n)
individual with spina bifida
parent
friend
family member
spouse
health care professional

I would like to receive announcements via:

Postal Service Email
* Required field