Brain Injury Association of MS Membership Form

Brain Injury Association of Mississippi

Membership Form

Your Membership in BIA of MS can .....

strengthen and expand support groups	promote supported employment services
maintain an information and referral service	promote enabling legislation
develop prevention and public awareness	sponsor conferences for families, survivors and professionals

I would like to help the Brain Injury Association of Mississippi continue its valuable work for survivors of TBI and their families. I understand that my membership fee is tax-deductible since BIA of MS is a nonprofit organization.

TYPE OF MEMBERSHIP:

Individual/Family $35

Student $20

Professional $50

Corporate $250 (includes 2 individual memberships)

Benefactor $500

Entry $5 (Membership will not be denied to any TBI Survivor or family member due to an inabilty to pay dues).

I would like to become a BIA of MS FRIEND, working to improve the quality of life for survivors of Traumatic Brain Injury and their families by making a special donation of: $___________ .

I would like to make a donation designed for the 800# Helpline: $_______________ .

Please make checks payable to the Brain Injury Association of Mississippi, P.O. Box 55912, Jackson, MS 39296-5912

I am a

Suvivor of a head injury . . . . . . . . . . . . . . Family Member

Professional - Discipline __________________________________________________

Friend/Concerned member of the community

Name __________________________________________

Address ________________________________________

_______________________________________________

Telephone (H) _______________ (O) _________________

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