GRSBA Membership Application

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(2022 Membership Fee waived this calendar year)

Name: *

Address: *

Phone: *

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Email address: *

I hereby apply for membership of the Greater Rochester NY Spina Bifida Association (GRSBA) and declare that the information provided below is accurate and up to date: *

Agree

Required

Please indicate whether you are interested in serving on a GRSBA Committee:

Public Awareness / Education and Public Awareness

Advocacy

Social Media / Advertisement & Promo

Spina Bifida Community Needs Assessment

Social Gatherings and Events

Fundraising / Development

Other:

I have read and understand the mission of GRSBA (Mission Statement and By-Laws can be found on the GRSBA website www.GRSBA.Org). *

If using a printed version of this form, please sign and date below. Submit your application electronically below or mail to GRSBA, PO Box 3, Fairport NY 14450.

By checking this box I affirm I want to be a member.

Required

Please note that membership fees for 2022 are waived. Following the General Meeting and Election, membership dues will be determined and announced for the 2023 calendar year.

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