NSCIA CT Chapter Online Membership Form
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NSCIA Online Membership Form

In order to fullfill your request, we ask that you please fill out and submit the information in the form below so that we may begin processing your membership information. You will be billed shortly via regular mail based upon the type of membership you have selected. You may click here to review CT Chapter Membership benefits and information.

As always, you have our personal guarantee that this information will be kept private & confindential and will only be used for the purposes of our membership benefits and services! If you do not wish to submit this information over the Internet, you may call the CT Chapter directly at (203) 284-1045 and request that a Membership form be sent to you via regular mail.

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  (Ex: "MyName@MyISP.com")
Is this a NEW membership? Choose "No" if you wish to RENEW an existing or lapsed membership?
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  (Ex: CT, NY, RI)

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Membership Type:
Sponsored Membership/Newly Injured - One year free!
$10 - Individual Membership
$20 - Family Membership Renewal
$100 - Individual Lifetime Membership
$500 - Corporate Membership
$1000 - Silver Membership
$5000 - Gold Membership
$10,000 - Platinum Membership
Disability:
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Please be patient until the Confirmation Screen Appears. Thank you!

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Disclaimer (Please read this item carefully!) The information contained in this web site is not intended or implied to be a substitute for professional medical advice. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
The National Spinal Cord Injury Association, CT Chapter does not directly or indirectly practice medicine or dispense medical services or medical advice. NSCIA does not assume any liability for the information and data contained in this web site or for any diagnosis or treatment made in reliance thereon.
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