Membership Form

Membership Form

Please fill out your details to join or renew your membership.
This form must be filled out and returned with dues to be a paid member. The dues can be mailed by check to SBKC - Membership P.O. Box 901383 Kansas City MO 64190 (make checks payable to Spina Bifida Kansas City), or paid through paypal - see QR code below
Date

MonthDayYear
Date
$100 - per SB individual (regardless of age, family memers are included)*

* for example if you have 2 SB individuals living in your home, the membership would be $100 each.
Full Name

First NameLast Name
Email Address
example@example.com
Relationship to individual with Spina Bifida
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
Date
Name of Person with Spina Bifida
Volunteer Interests
PayPal Payment
Should be Empty: