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

 

Please share the record of my membership with the following local support group of the Brain Injury Association of Ohio:

 

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:

Please make checks payable to the Brain Injury Association of Ohio, 855 Grandview Ave., Suite 225, Columbus, OH 43215.

Donations gratefully accepted!  Thank you!

Call if you have any questions, 1-866-644-6242 (toll free in Ohio) or 614-481-7100 or help@biaoh.org