Renew or become a member now! Thank you for helping turn the mission and vision of the Foundation into reality!
If you prefer to mail a check for your membership, the form below may be used.
The membership levels are as follows:
- Annual Membership (current calendar year) – $30
- Lifetime Silver Membership – $250
- Lifetime Gold Membership – $1000
- Lifetime Platinum Membership – $5000
- Lifetime Diamond Membership – $10000
Street Address / P.O. Box: ________________________________
City: ____________________________ State: ______ Zip: ______
Telephone/TTY: Home: ________________Work: ______________
E-Mail Address: _________________________________________
I am a Parent___ Relative___ Professional___ Friend___ Individual with CHARGE___
May we give this information to other parents? Yes___ No___
Name of Individual with CHARGE: ________________ Birthdate: _________
Please select your preferred membership level below:
New ____ Renewal ____
Annual — Current Calendar Year
___Lifetime Silver Membership
___Lifetime Gold Membership
___Lifetime Platinum Membership
___Lifetime Diamond Membership
Additional tax-deductible contribution: $ ___________
Total Amount Enclosed $ ______________________
Please complete and mail with membership fees/contributions to:
CHARGE Syndrome Foundation Inc.
318 Half Day Rd #305
Buffalo Grove, IL 60089
For a printable version of this form see: Membership Form.