(mail check payable to TRIO & send to address located at bottom of page)
First Name, ________________________Mi,___ Last Name,______________________
Street __________________________________________________________________
City, _____________________ State, _______ Zip Code _________________________
Male____Female_______Daytime Ph_______________Evening Ph_________________
MEMBERSHIP CATEGORY (PLEASE COMPLETE APPROPRIATE CATEGORY)
Regular (Transplant Candidate, Transplant Recipient, Family Member) - Circle one
Individual and Family Membership @ $40.00
Additional voluntary contribution or donation:* ____________________
(*TRIO is a 501©(3) Tax Exempt Organization, Group Extension #3268; EIN #54-1603765)
For additional memberships, please list names and address on a separate sheet of paper.
Membership grants are available, for information call (703) 928-8746
Health Care Professional (Surgeon, Physician, Clinical Coordinator, Nurse, Social Worker, Other) - Circle one @ $25.00
" Friends of TRIO" - Contributing Annual Memberships
*Tax Exempt ___________Founder ________________($100 to $199) _______________________
Organization___________Donor __________________($200 to $499) _______________________
EIN # 54-1603765_______Patron _________________($500 to $999) _______________________
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