Spina Bifida Association of Alabama Membership Form

We firmly believe that every form completed is another “voice” to help gain supporters, grants, and sponsors. There is no fee for membership. Each person who responds can draw more public and political attention to our mission to promote prevention of Spina Bifida through folic acid awareness while enhancing the lives of all currently affected. Please help us make a difference by completing and returning this information.

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!