Spina Bifida Association of Alabama

Your name:

Address:

City:

County:

State:

Zip:

Phone (Day):

Phone (Evening):

Phone (Cell):

E-mail:

Name of person with Spina Bifida:

Person With SB is:

MaleFemale

Please check all items that best describe you:

Parent of a child w/SB
Adult with SB
Family member with SB
Friend/Supporter
Medical Professional
Other
If you are a parent of a child with SB:

Child's name:
Child's Date of Birth:

If you are an adult with SB:

Your Date of Birth:

Race:

White
Black
Asian
Hispanic
Other

I/We am/are willing to be included in the directory

I/We am/are willing to be contacted as a source of support to individuals/families affected by Spina Bifida

Spina Bifida Association of Alabama Membership Form

Donations are welcomed!