Spina Bifida Association

of Washington State

THE SPINA BIFIDA ASSOCIATION OF WASHINGTON STATE

Formerly the Evergreen Spina Bifida Association

MEMBERSHIP CONTACT APPLICATION FORM

Name:                                  ____ ______Spouse’s Name: ______________________

Street Address:            _____________

City:                                             

County _________________________________State: _____ Zip: ____________

Home Phone:                                           Other Contact Phone __________________

Email Address: ___________________________  

Person with Spina Bifida: _________________________Date of Birth: __________

Total number in immediate family _____

Today’s Date __________________

Please complete this form and return to:

Spina Bifida Association of Washington State

611 2nd Avenue, Suite A
Snohomish, WA  98290

Email to: sbaws@yahoo.com

No one will be denied membership for inability to pay.  If this form is completed and returned, you will be a full member of the Spina Bifida Association of Washington State

Please send a donation of any size to help us reach out to those affected by Spina Bifida.  The Spina Bifida Association of Washington State will pay for our members subscriptions to the national Spina Bifida Association so that they will receive the national SBA’s newsletter/magazine “Insights”.

Our newsletter “The Evergreen”  will be available on this web site and will be emailed to all members unless a special request is made to have it printed and mailed via the United States Postal Service.

formerly, The Evergreen Spina Bifida Association