NSCIA MEMBERSHIP FORM
National Spinal Cord Injury Association
8300 Colesville Road, Suite 551, Silver Spring, Maryland  20910
Phone (301) 588-6959    Fax (301 588-9414

Name:  ________________________________  Organization:  _______________________________________

Address: ________________________________________	Daytime Phone:  _(____)______-__________

               _________________________________________	Email:  _______________________________      

City:  ___________________  State:  _____  Zip: ________	Age:  __________

Country:  _______________________  
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TYPE OF MEMBERSHIP
Please check one.

		Description							  Amount
____ 	Individual with spinal cord injury						    $25.00
	Level of injury (e.g. C-4, T-12, L1, etc.)  ________

____	Family Member								    $25.00

____	Health Care Associate							    $50.00
	(Social Workers, PT, OT, RN)

____ 	Professional								   $100.00
	(MD, PhD, JD)

____ 	Foreign Member 								   $100.00
	(funds drawn on US Bank only)

____ 	SCI Facility								   $100.00
	(Hospital, Clinic, Independent Living Center)

____	Silver Organization Member						   $250.00
	(Organization/Corp. Budget under $1 million)

____	Gold Organization Member							   $500.00
	(Organization/Corp. Budget over $1 million)

____ 	Platinum Organization Member						$1,000.00

____	In Touch With Kids							  FREE!
	(children with SCI, under 18 years old)				      (for children only)

I would like to make an additional donation of $______________.
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Would you like to receive mailings from other organizations?
Occasionally, NSCIA makes its mailing list available to select individuals and organizations for their mailings.  If you would not like to receive these mailings, please indicate below.

____     Do not distribute my address.
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Payment Information:
____  Check          ____  Money Order          ____ Visa          ____ MasterCard          ____ Amex
MAKE CHECKS PAYABLE TO:  National Spinal Cord Injury Association (Drawn On US Bank Only)
I hereby authorize National Spinal Cord Injury Association to charge my credit card for the above charges.

Name As It Appears On Credit Card: ________________________________________

Credit Card #: ___________________________   Expiration Date: ________________

Signature:  __________________________________________  Date: ____________