Brain Injury Association of West Virginia, Inc.
A state affiliate of the Brain Injury Association, Inc.
Membership Application
Name: __________________________________________________________________
Address: ________________________________________________________________
City/State/Zip: ___________________________________________________________
Phone: Home____________________________Work________________________________
E-mail: _________________________________ Fax: _________________________
_
I’m interested in serving on a committee.Membership Category: Please Check One
| _ Basic $35 | _ Corporate $200 | _ Person who has had a brain injury | |
| _ Supporting $50 | _ Patron $500 | _ Family member | |
| _ Professional/Provider $50 | _ Professional/Provider | ||
| _ Century Club $100 | _ Friend of BIA-WV |
Membership amount: __________
Donation* (if any): __________
Total amount enclosed: __________
Members of the Brain Injury Association of West Virginia will receive the quarterly BIA-WV newsletter, Moving Ahead and the national BIA newspaper, TBI Challenge. Members will also receive notices of meetings and conferences, legislative issues and alerts, and access to the BIA-WV resource library of videos, printed materials, and audio cassettes.
Make checks payable to: BIA-WV
Mail payment to: PO Box 574, Institute, WV 25112-0574