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Membership Form

Renew or become a member now! Thank you for helping turn the mission and vision of the Foundation into reality!

become a member

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

Name: _______________________________________________

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.