Prader-Willi Syndrome Association Of Indiana

2001 Membership Application

PWSA of Indiana is a non-profit organization dedicated to supporting individuals with Prader-Willi Syndrome and their families, through advocacy, education, and awareness.

Name:______________________________________________________________

Address:____________________________________________________________

City:_____________________     State:_______________     Zip:______________

Phone:(      )                              _______             E-mail:_______________________

Please Check One:

Renewal:______     New:______    

Please Check One:

Parent:______________________                     Family Member:______________              

Friend:__________________________             Professional:_________________

Date of Birth:____________________                Sex:________________________

Name of Individual with PWS:________________________________________

I/We authorize PWSA of Indiana / PWSA (USA) to include the above information on the chapter mailing list, and to publish the information in the chapter membership directory. I/We further authorize PWSA of Indiana / PWSA (USA) to use and/or publish photograghs of the above individuals in press releases, newsletters, brochures, and other informative publications.

________________________________________                    _______________________

Signature - Head of Household                                            Date

Click Here To Return To The Home Page