ANNUAL MEMBERSHIP APPLICATION FORM

Date:_____________________
Name: _____________________________________________________
Address: ____________________________________________________
____________________________________________________________
City, State and Zip: ____________________________________________
Phone: _______________________________
Fax: _________________________________
Email: _________________________________________

Please check all that apply:
__ Courtesy (Head Injury Survivor) - $5.00
__ Parent/Student Athlete-$25
__ Basic (Individual) - $35
__ Family Member - $50
__ Professional - $100 What Field? ___________________________________
__ Agency/Organization - $200 ______________________________________
I'm pleased to enclose an additional contribution of $_________ to support the important work of BIAWA.
Total Amount Enclosed: ___________________

Payment Method: (Please make all checks payable to BIAWA)
___ Payment Enclosed        ___ Master-Card        ___ Visa
Charge Card Number: ___________________________________________
Name as it appears on card: (Please Print) ___________________________
Amount: _____________ Expiration Date: _______________________
Signature: ____________________________________________________

Please mail this form with payment (or payment info):
Brain Injury Association of Washington
3516 S. 47th Street, Suite 100
Tacoma, WA 98409
Tel 253.238.6085
Fax 253.238.1042
Helpline 1.800.523.5438