Membership Registration
Register to become a member of SWDSC!
Your Name
*
First Name
Last Name
Spouse's Name (if applicable)
First Name
Last Name
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Email Address
*
example@example.com
Spouse's Email Address (if applicable)
example@example.com
Would you like to subscribe to our news/events
YES
NO
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Phone
*
Please Select
Videophone
Text
TTY
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Phone
*
Please Select
Voice Phone
Videophone
Text
TTY
Membership Dues
*
$10 per person, $15 per couple
Additional Donation
Donations are appreciated, not required.
Total Enclosed
*
Signature
Please make checks payable to SWDSC. Print and mail form to: Roberta Letkiewicz, SWDSC Membership Coordinator. W201 N11402 Oakview Avenue, Germantown, WI 53022. Thank you!
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