Make A Difference in the Lives of Individuals with Brain Injury! Support BIAWA, Join Today! Please print out, fill in, and mail this form to apply.

MEMBERSHIP APPLICATION FORM

Name: _____________________________________________________

Address: ____________________________________________________

____________________________________________________________

City, State and Zip: ____________________________________________

Phone: _______________________________

Fax: _________________________________

Email: _________________________________________

Please check all that apply:

__ Courtesy (Head Injury Survivor) - $5.00

__ Basic (Individual) - $35

__ Family Member - $50

__ Professional - $100 What Field? ___________________________________

__ Agency/Organization - $200 ______________________________________

I am pleased to enclose an additional contribution of $_________ to support the important work of BIAWA.

Total Amount Enclosed: ___________________

Payment Method: (Please make all checks payable to BIAWA)

___ Payment Enclosed        ___ Master-Card        ___ Visa

Charge Card Number: ___________________________________________

Name as it appears on card: (Please Print) ___________________________

Amount: _____________ Expiration Date: _______________________

Signature: ____________________________________________________

Please mail this form with payment (or payment info) to:

Brain Injury Association of Washington
3516 S. 47th Street, Suite 100
Tacoma, WA 98409
Tel 253.238.6085
Fax 253.238.1042
Helpline 1.800.523.5438