Wheeling and Able

Membership Form

Name: ____________________________________________________________________________

Address: ___________________________________________________________________________

City: ________________________________ State: _________ Zip Code:_____________________

Home #: _________________________________ Work #: _________________________________

Fax #: ___________________________________ Email #: _________________________________

Disability: _____ Para _____Quad _____Able-Bodied _____Other (specify) _______________

__________ Sponsored Membership/Newly Injured

__________ $10 Individual Membership

__________ $20 Family Membership Renewal

__________ $100 Individual Lifetime Membership

__________ $500 Corporate Membership

__________ $1000 Silver Membership

__________ $5000 Gold Membership

__________ $10,000 Platinum Membership

***Also enclosed is $ _________ as a tax-deductible donation to the NSCIA Ct-Chapter.

Complete and mail to the National Spinal Cord Injury – Ct Chapter, PO Box 400, Gaylord Farms Road, Wallingford, CT, 06492

For More Information contact the NSCIA-Ct Chapter at 203 – 284 –1045 or Email nsciact@iconn.net or visit our Web Site at http://www.nsciact.org.