Yes, I would like to join the Chesapeake-Potomac Spina Bifida Association

( ) Individual ( ) Family ( ) Professional ( ) Patron ( ) Benefactor

$30 $35 $50 $100 $250+

Enclosed is my membership donation of $ _________.

( ) I would like to join, but I am unable to make a donation due to financial hardship

I am a ( ) parent of a child with spina bifida ( ) an adult with spina bifida ( ) a relative ( ) other: _______________

Please make check payable to and mail to:

Chesapeake-Potomac Spina Bifida Association
P.O. Box 1750
Annapolis, MD 21404

Please check below if you would like to:

( ) Receive more information about CPSBA

( ) Become a volunteer

( ) Make a non-monetary donation to CPSBA

    Describe:________________________________________________

NAME: ______________________________________________

ADDRESS: ___________________________________________

               ____________________________________________

               ____________________________________________

EMAIL:     ____________________________________________

PHONE: _(_____)________________

For further information, contact the association at 1-888-733-0988.