of Greater Pennsylvania Read Carefully - New Options!!
215 E State Street, Suite D, Quarryville, PA 17566-1268
Check kind of membership (choose one or we will consider you Local only)
____ National and local: receive SBAA and Greater PA�s newsletters (80% of your fee goes to SBAA)
____ Local only: to receive SBA Greater PA�s newsletter only (100% of your fee stays here)
____ I belong to another chapter but would like your newsletter ($25 fee). Chapter ___________________
Mailing address
name ________________________________________________________________________________________
company or organization ________________________________________________________________________
address ______________________________________________________________________________________
address __________________________________________________ county _____________________________
city, state & zip _______________________________________________________________________________
home phone ___________________________________ work phone ____________________________________
email address ________________________________________________for ______________________________
email address ________________________________________________for ______________________________
Email options: Help us save postage and paper. Check items you would like to receive by email:
____ Newsletter ____ Spina Bifida notes ____ Education issues ____ Legislative issues
____ SBAA info
New chat rooms: ____ SB parents ____ SB adults Chat with other parents or other adults across the country.
Check type of membership (must choose one)
_____ $25 Consumer* - household of an adult with SB Spouse�s name __________________________________
_____ $25 Family* - household of parent(s) or guardian(s) of child/children born with SB
_____ $30 Relative - of a person born with SB ___________________/___________________________________
relationship person with SB
_____ $50 Professional or Agency � works with those born with spina bifida.
field _________________________________________ title _________________________________
_____ $30 General � friend to the Association
*____ Consumers or Family members in PA, who cannot afford membership at this time, may check here to request that the membership fee be waived. Full membership granted.
Consumer and family information: (list additional persons with their information on separate page)
Person with SB ___________________________________ (male female) birth date ___________________
High school graduation year ______________ ____ do not list my birthday or graduation in newsletter
Do you attend a Spina Bifida Clinic? yes no Which one(s) _____________________________________
Mom�s full name ______________________________ Dad�s full name __________________________________
Lives with (please circle): parent(s) spouse alone other ____________________________________
Working _____ hours per week Not working because ____________________________________________ ______________________________________________________________________________________________
Please list all family members� employers, as this may help us get grants. Circle any with matching gift programs. ____________________________________________________________________________________________
____________________________________________________________________________________________
Questions or concerns __________________________________________________________________________
____________________________________________________________________________________________
Thank you for your support!
Please make checks payable to SBAgPA Membership fee ___________________
Donation + _________________
Total enclosed $ _________________
What Is It?
Calendar Links Folic Acid & Prevention
