Membership Application
TRIO - The Nation's Capital Area Chapter

Please print this form, fill it out, and mail (along with check) to TRIO (address given at bottom of page).

First Name:_____________________________________
Middle Initial:_____________________________________
Last Name:_____________________________________
Street:_____________________________________
City:_____________________________________
State:_____________________________________
Zip:_____________________________________
Daytime phone:_____________________________________
Evening Phone:_____________________________________
Please check one: ... ( ) Male ... ( ) Female

MEMBERSHIP CATEGORY (please complete appropriate category)
Regular (Transplant recipient, transplant candidate, Family member; donor and donor family) -- circle one

Individual Membership @ $25.00
Family Membership (two members at same address) @ $35.00
Additional Members at same address @ $10.00
Additional Members at different address @ $15.00
Additional voluntary contribution: [your choice]

For additional memberships, please list the names and addresses on a separate sheet of paper.

Membership grants are available. For information contact Linda Cheatham (703) 698-0083

Health Care Professional (Surgeon, Physician, Clinical Coordinate, Nurse, Social Worker, Other) @ $25.00

"Friends of TRIO" - Contributing Annual Memberships
_____Founder ($100 to $199)
_____Donor ($200 to $499)
_____Patron ($500 to $999)
_____Angel ($1,000 and up)

MEMBER PROFILE (OPTIONAL)

Type of transplant: ________________
Date of transplant: ________________
No. of transplants: ________________
Transplant Center: ________________
City/State:
Time waited:________________
Comments: ________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

INTERESTS

I want to get involved right away - Please have someone from the following chapter committee(s) contact me!
___Organ and Tissue Donor Awareness
___Policy/Legislation
___Newsletter
___Membership
___Meetings
___Support
___Fundraising
___Public Relations

Organ & Tissue Donation -- Share Your Life. Share Your Decision.

The Nation's Capital Area Chapter
Transplant Recipients International Organization
P.O. Box 7633, Arlington, VA 22207
(703) 920-TRIO

Return to the TRIO - National Capital Area Chapter index page

Last modified: 11 May 2000

Membership ApplicationTRIO - The Nation's Capital Area Chapter

Membership Application
TRIO - The Nation's Capital Area Chapter