SBWNY Membership Application
If your child with Spina Bifida is younger than 18 yo (or you are the guardian of an individual with Spina Bifida ), you are considered the Primary Member.
Primary Member's First and Last Name
*
First Name
Last Name
Primary Member's Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Does Primary Member have Spina Bifida
*
Please Select
Yes
No
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Phone Type
*
Cell Phone
Home Phone
Work Phone
Interested in Volunteering
*
Yes
Not at this time
Member with Spina Bifida(SB) First and Last Name
*
First Name
Last Name
Member with SB Birth Date
*
-
Month
-
Day
Year
Date
Member with SB Gender
*
Please Select
Male
Female
Prefer not to disclose
Member with SB relationship to Primary Member
*
Please Select
Self
Daughter
Son
Sister
Brother
Granddaughter
Grandson
Other
Individual with SB Immediate Family Members
As part of our ongoing effort to enhance lives of individuals and families affected by Spina Bifida we try to include immediate family members in our events. Based on funding availability we strive to provide a discounted or no cost admission to the immediate family members of the Individual with SB. Please list all immediate family members and their relationship to the Individual with SB in order to receive an invitation to the available events and/or discounted or free admission, when applicable.
Immediate Family Member 1
Full Name
Age
Relationship to the Individual with SB
Immediate Family Member 1 Date of Birth
-
Month
-
Day
Year
Date
Immediate Family Member 2
Full Name
Age
Relationship to the Individual with SB
Immediate Family Member 2 Date of Birth
-
Month
-
Day
Year
Date
Immediate Family Member 3
Full Name
Age
Relationship to the Individual with SB
Immediate Family Member 3 Date of Birth
-
Month
-
Day
Year
Date
Immediate Family Member 4
Full Name
Age
Relationship to the Individual with SB
Immediate Family Member 4 Date of Birth
-
Month
-
Day
Year
Date
Immediate Family Member 5
Full Name
Age
Relationship to the Individual with SB
Immediate Family Member 5 Date of Birth
-
Month
-
Day
Year
Date
Immediate Family Member 6
Full Name
Age
Relationship to the Individual with SB
Immediate Family Member 6 Date of Birth
-
Month
-
Day
Year
Date
*
I hereby affirm that the information provided on this form is true and complete.
Signed
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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