Membership Application

Please identify and describe yourself:

Name
Agency
Address
City
State
Zip
Business Phone
Home Phone
E-mail
	Would you like to join our email list for future announcements and newsletters?   yes  no  (Note that email address will not be distributed outside of the Brain Injury Association of Ohio.)
Age	(optional)
Sex	Male Female  (optional)
Status	New Membership Renewal

 

 

Choose one of the following options:

Person with brain injury Parent Spouse Sibling Child Other Family Member Friend Professional

 

Please select your membership type:

Regular Membership, $35.00 Constituent Membership (see below)

Constituent Memberships do not require annual renewal.  This category is for individuals with brain injury or their families who cannot afford the annual membership fee, but want to receive Association mailings.  All privileges of membership apply, except voting and holding office.

Note or Comments:

After Choosing the Submit button below, a new window confirming your membership details will appear.  If you are applying for a  regular, paying membership, return to this page and choose the Pay button to finish your application.