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Annual
Membership Form Please
print/complete this form and mail or fax to: Tourette Syndrome Association of Greater Washington 33 University Boulevard E. Silver Spring, MD 20901-2485
Fax: 301-681-4183 Please contact us if you have any questions. If you plan to pay your membership fee by credit card, you can send this form by email. Click here to see how to email this form.
The
following information will help the Tourette Syndrome Association serve the
needs of your family. Any
information you supply is strictly confidential. Name_________________________Spouse_________________________Date__________ Street___________________________________________Apt.
#__________ City__________________________County__________________ State___________Zip
Code_________ Phone
(Home)_________________________ (Work)__________________________
E-mail
(Home)_________________________(Work)__________________________________
Relationship to Person with TS: [ ] Self [ ] Parent [ ] Teacher [ ] Physician
[ ]
Grandparent
[ ]
Other_______________ Persons
with TS: Name_______________________________
Name_______________________________ Date of
Birth______________Gender_____
Date of Birth______________Gender_____ Currently
on Medication: [ ]
Yes [ ]
No
Currently on Medication: [ ]
Yes [ ]
No Ethnicity of Patient: (this is used for demographic purposes only) [ ]
African American [ ]
Latin American [ ]
Native American [ ] Other______________ Annual
Membership: Dues
include membership to the National Tourette Syndrome Association and our local
chapter (TSAGW)
Please
start my [ ]
new membership /
[ ]
membership renewal at the following level: [ ]
$45 Individual Member ($33 supports
national TSA, $12 supports TSAGW) [ ]
$60 Family Membership (2 votes) ($44
supports national TSA, $16 supports TSAGW) [ ]
$60 Professional Member (Ph.D., CSW, RN,
PA, etc.) [ ]
$100 Physician Member [ ]
$125 Contributing Member [ ]
$250 Sustaining/Corporate Member [ ]
$500 Patron Member [ ]
$5000 Lifetime Member [ ]
I cannot afford membership at this
time. Please enroll me as a TSA Scholarship Member for the next year. [ ]
I would like to make a donation to support
my local chapter’s programs and services. Enclosed
is a $______ donation to TSAGW (separate check please payable to TSAGW).
Payment
type: [ ]
Check/Money Order Enclosed (payable to
TSA, Inc.) [ ]
MasterCard [ ]
Visa [ ]
Discover Card Number: [ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ] [ ][ ][ ][ ]
Exp. Date:____/____ Signature:_______________________ Membership
Directory: I would like to be listed in the Chapter Member Directory to aid me in networking with the other members and families. [ ]
Yes [ ]
No Signature______________________________________ Volunteering: I would like to help TSAGW fulfill their mission by volunteering the following services and skills: _____________________________________________________________ Physician’s
information: By
providing us with your doctor’s information, you will enable TSAGW to forward
literature to your physicians that will help them spread the word about TS, and
make others aware of the Tourette Syndrome Association. Current
TS Physician’s Name: ___________________________Specialty___________________ Physician’s
Address_____________________________________________________________ City____________________________________State_________
Zip Code _________________
Thank
You for Joining TSA. Your support makes a difference.
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