Last modified: 11 May 2000
If you would like to apply for membership, print out this form, fill it out, and mail it to TRIO at the above address.
I hereby apply for membership in the New England Chapter of TRIO.
NAME(S)_______________________________________________________
Description ____Recipient____Family member____Donor Family
____Candidate____Interested Individual____Professional
Home Address:____________________Business Address:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Home Phone:____________________Business Address:______________
PERSONAL INFORMATION (optional):
Date of Birth____________________Employment___________________
SEX__________ETHNICITY_______Marital Status_________________
CANDIDATE/RECIPIENT INFORMATION:
Number of transplants____________Type of Transplant(s)___________
When__________________________Time waited(or waiting)_________
Where___________________________________________________________
HOW WOULD YOU LIKE TO HELP?
____Speaker____Contributor____Membership
____Hospital visitor____Clerical____Other_________
____Fund-raiser____Newsletter____Sorry, too busy.
REMARKS:_____________________________________________________________________________________________________________________________
__________________________________________________________________
TYPE OF MEMBERSHIP
____Active $15.00____Institutional _____Family $25
Make check payable to the New England Chapter of TRIO and mail it to:
TRIO New England
Lakeside Office Park
607 North Ave, Door #14
Wakefield, MA 01880
I understand that TRIO New England does not engage in organ procurement or fund-raising for any individual candidate, recipient, or family.
___________________________________________________
Signature and Date
TRIO New England does not release the names, addresses, or phone numbers of the members of its chapters without their permission.