BIA-Hi Membership Form
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NAME___________________________________________________________

TITLE___________________________________________________________

COMPANY_______________________________________________________

ADDRESS________________________________________________________

________________________________________________________________

CITY ________________________________STATE_________________

ZIP__________________________

TELEPHONE (home)____________________

(business)___________________ (fax)______________________

EMAIL ADDRESS ________________________________________________________________

__ Yes, I want to join BIA-HI

__ Courtesy membership (sponsorship available)

__ Individual Membership ($10 per year)

__ Family Membership ($15 per year)

__ Professional Membership ($25 per year)

__ Organizational Membership ($50 per year)

__ I enclose a financial contribution to support your work.

__ $10 __ $25 __ $50 __ $75 __ $100

__ other _________________

__ I want to contribute ideas and energy. Please call me.

___ I would like to be on the BIA-HI email update list

___ Please do not distribute my address to the membership

Please send this form with your check to:
Brain Injury Association of HAWAII
420 Kuwili Street, Suite 103
Honolulu, Hawaii 96817

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