If you are interested in joining, please print this form and mail it to the
address at the bottom. Thank you!
Name: ____________________________________
Address: _________________________________
City: ____________________________________
State: ______________ Zip: _______________
Phone: ___________________________________
E-Mail: __________________________________
___ Yes, I want to become a member of the National Hydrocephalus Foundation.
I understand the annual membership fee is $35.
___ I would like to make a tax-deductible donation of $________
Method of Payment:
___ Check
___ Credit Card: Visa ___ Master Card ___
Total Amount to be Charged: $_______
If you are using a credit card, provide the account information here.
Name of Card Holder: ________________________________
Account Number: _____________________________________
Verification Number (on back of card):_______
Expiration Date: _________
Signature:________________________________________
___ I would like to be a parent-to-parent or adult-to-adult referral. (circle one)
Please provide some information about the individual with hydrocephalus.
Name of Person with Hydrocephalus: _________________________________
Type of Hydrocephalus: _____________________________________________
Age When Diagnosed: ______________
Current Age: _____________________
Other information you would like to provide and/or medical conditions:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
I hereby give my permission to have my contact information given to another individual
and/or family in which I might be able to assist.
Signature: ________________________________________________
Date: ____________________
Mail to:
National Hydrocephalus Foundation
12413 Centralia Rd.
Lakewood, CA 90715-1623
Questions or comments?
Phone: 562-924-6666
Phone: 888-857-3434
Federal Tax ID: 36-3218744
Thank you for your contribution!
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