Membership Application TRIO - Nation's Capital Area Chapter

For the most current membership information please visit http://www.trio-ncac.org/.

(mail check payable to TRIO & send to address located at bottom of page)

First Name MILast Name

Street

City StateZip Code

Male Female ( ) ( )

(check one) Daytime Phone Evening phone

MEMBERSHIP CATEGORY (PLEASE COMPLETE APPROPRIATE CATEGORY)

Regular (Transplant Candidate, Transplant Recipient, Family Member) - Circle one

Individual Membership @ $25.00

Family Membership (Two members at same address) @ $35.00

Membership grants are available.

For information contact Linda Cheatham 703-698-0083.

Additional members at same address @ $10.00

Additional members at different address @$15.00

Additional voluntary contribution:

(TRIO is a 501(c)(3) Tax Exempt Organization)

For additional memberships, please list names and address

on a separate sheet of paper, or on the other side of this form.

Health Care Professional (Surgeon, Physician, Clinical Coordinator,

Nurse, Social Worker, Other ) @ $20.00

"Friends of TRIO" - Contributing Annual Memberships

Founder ($100 to $199)

Donor ($200 to $499)

Patron ($500 to $999)

Angel ($1000 and up)

MEMBER PROFILE (OPTIONAL)

Type Of Transplant: Date of Transplant:

No. of Transplants: Transplant Center:

City: Time waited:

Comments:

I want to get involved right away - Please have someone from the following chapter committee(s) contact me!

Donor awareness Policy/Legislation Programs

Newsletter Membership Mentor

Meetings Public Relations Olympics

Finance/Fundraising Resource Guide Donor Appreciation

TRIO - The Nation's Capital Area Chapter, P.O. Box 7633, Arlington, VA 22207-7633