Instructions: Please print the form and fill it out. Send the form with your membership fee to BIAW. Make checks payable to Brain Injury Association of Wisconsin.
BIAW
21100 W. Capitol Drive, Suite 5
Pewaukee, WI 53072
BIAW Membership Application
| Name | New | Renewal | |
| ___________________________________________ |  |
|
City _______________________________State ______________
County _____________________ Zip _____________________
Home Phone _______________________ Work Phone _______________________
Email Address ________________________________________________________
Type
of membership:
Individual $35.00
Professional $50.00
Patron $100.00
Corporate $200.00
Benefactor $500.00
Founder $1000.00
Additional Donations: $
_____________
Please
identify: I am . . .
an individual with a brain injury
family of an individual with a brain injury
spouse _____ sibling _____ parent
_____
friend of BIAW
professional
field _____________ agency _____________
As a BIAW member, you will receive a renewal letter in the month your membership expires. Thank you for your new or continued support. Donations for a memorial or commemorative occasion may be made by sending your check payable to BIAW. Thank you.