Associate Membership Application

Currently Being Updated

Last Name

First Name

Address

City

State

ZIP

Phone

Alternate Phone

Gender

Date of Birth

Do you have a Spinal Cord Injury or Disease?

Are you a veteran?

Optional: there is no cost for Associate Membership in PVA-WI; however, donations are gratefully accepted and are 100% tax-deductible. If you make a donation now or in the future, you will receive a letter acknowledging your charitable contribution for your tax purposes. As an Associate Member of PVA-WI, you will receive our quarterly newsletter, and you may contact us at any time for information, comments, or questions.

Signature

Date