SICKLE CELL DISEASE ASSOCIATION OF FLORIDA, INC.

GENERAL MEMBERSHIP APPLICATION


Join today and become one of SCDAF supporters! The work of the Association advocacy, educational awareness, services and programs to enhance and improve the quality of health care for individuals and individuals impacted by sickle cell disease - depends on the support of caring individuals like you. A strong membership base is our hope for change and improvement in services and programs.

MEMBER INFORMATION INSTRUCTIONS
Prefix
First Name *
Middle Name
Last Name *
Suffix
Email Address *
Are you involved with a sickle cell chapter?
Yes     No
Would you like more information about a sickle cell chapter in your area?
Yes     No
* Required Information
Address *

City *
State *
ZIP Code *
Country
Telephone

Please enter your name as you wish it to appear on your membership card.

Enter the address at which you wish to receive your membership information.

MEMBERSHIP OPTIONS
Membership Levels
General Membership - $25
Associate Membership - $100
At-Large Membership - $100

Please choose the membership level at which you would like to join.

BILLING INFORMATION
Card Type *
Name on Card *
Card Number *
Expiration Date *
* Your account will be charged

Same as Membership Address
Email Address *
Address *

City *
State *
ZIP Code *
Country
INSTRUCTIONS

Enter your credit card information and billing information. This may be different from the Member Information above.

If you would prefer to join by mail, you may download the membership form (PDF) and mail it to:

Sickle Cell Disease Association of Florida, Inc
Membership Department
P.O. Box 11982
Tampa, FL 33680-1982

Note: Only click the button below once. Confirm the accuracy of the information you have entered, then use the "Join Now" button to proceed. Please close your browser once you complete your transaction (Do not hit the Back or Refresh button). Otherwise your payment may be processed twice.



Sickle Cell Disease Association of Florida, Inc
P.O. Box 11982
Tampa, Fl 33680-1982


Local: (813) 248-2888

© 2009 SCDAF
All Rights Reserved


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