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Joining The Derby City Chapter of the National Spinal Cord Injury Association is easy as 1-2-3...

  1. Print this page
  2. Fill in the blanks
  3. Mail form & donation to address at bottom

THE DERBY CITY NSCIA NEWSLETTER

You are cordially invited to join us!

The Derby City Chapter of the National Spinal Cord Injury Association
consists of people with spinal cord injuries and similar physical conditions, their family members, friends, and
professionals or other interested parties.

We meet:

WHEN- Third Monday of every month from 6:30 to 9:00 PM
WHERE- Frazier Rehab Center , 4th floor Dining Room
220 Abraham Flexner Way

If you wish to be a member, donor, and/or be on the mailing list of the Derby City Chapter of the National Spinal Cord Injury Association please complete and mail the following form to the address below

National Spinal Cord Injury Association
Derby City Chapter
Membership & Organization Sponsorship Form

Name: Mr./Mrs./Ms./Dr. ________________________________________ Date: ________

Address: ______________________________________________________ Apt.# _______

City/State/Zip: ______________________________________________________

Business (if any): ______________________________________________________

Home Phone: (____)____________________ Work Phone: (____)____________________

Date of Birth _______________________

Para: ______ Quad: ______ Hemiplegic: ______

Level of Disability __________________ Other Disability __________________

Able-Bodied(yes/no): ____________

New Member: __________________ Renewal: __________________

Newsletter Subscription (only $12): __________________

Special Interests /Hobbies/Sports: _____________________________________________

****

Membership is open to all individuals and sponsorship to all organizations interested in spinal cord injury.

Mark Type of TAX DEDUCTIBLE Individual Membership or Organization Donor Category Desired***

Regular-$12 ___________

Sponsor-$25 ___________

Patron $50 ___________

Benefactor-$100 ___________

Permanent- $1000/lifetime** ___________

Bronze Organization-$100-249 ___________

Silver Organization-$250-499 ___________

Gold Organization- $500-999 ___________

Platinum Organization-$1000-2499 ___________

Diamond Organization-$2500 0r Over. ___________

Please make checks payable to: NSCIA Derby City Chapter

David Allgood
6703 Triangle Drive
Louisville , KY. 40214