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THE SPINA BIFIDA ADVOCATES OF WASHINGTON STATE

Formerly the Evergreen Spina Bifida Association

MEMBERSHIP CONTACT APPLICATION FORM



Name:                                  ____ ______Spouse’s Name: ______________________


Street Address:            _____________


City:                                             


County _________________________________State: _____ Zip: ____________


Home Phone:                                           Other Contact Phone __________________


Email Address: ___________________________  


Person with Spina Bifida: _________________________Date of Birth: __________


Total number in immediate family _____


Today’s Date __________________


Please complete this form and return to:

Spina Bifida Advocates of Washington State

18909 N Dartford Dr

Colbert, WA  99005

Email to: info@sbaws.org


No one will be denied membership for inability to pay.  If this form is completed and returned, you will be a full member of the Spina Bifida Advocates of Washington State


Please send a donation of any size to help us support and reach out to those affected by Spina Bifida.



formerly, The Evergreen Spina Bifida Association