Membership and Information Request Form

Greater Boston Post-Polio Association
Membership and Information Request Form

If you would like to become a GBPPA member, or to obtain more information, this form may be filled out on-screen and printed, or printed blank and filled out by hand. Mail the completed form, with your dues check (made out to "GBPPA") if applicable, to:

GBPPA
1 Grove St.
P.O. Box 812726
Wellesley, MA 02482-0024.

We are not yet equipped to accept applications or requests for information over the Web.

GBPPA membership includes an annual subscription to our quarterly newsletter, TRIUMPH.
The GBPPA is non-profit and tax-exempt. Contributions to carry on its activities are tax-deductible.

I would like more information about post-polio syndrome. (If you are not paying dues at this time, please consider a $3 donation to cover copying and postage costs).
I would like to join the Association and am enclosing annual dues of $15 (individual or health care professional) or dues of $25 (for-profit organizations).
I would prefer not to pay dues at this time, but would like to become a member and receive newsletters.
I would like to make a tax-deductible contribution of $.I would like to be called by a GBPPA member (please be sure to enter phone number below).

Name:

Address:

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email:

Greater Boston Post-Polio Association Membership and Information Request Form

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Greater Boston Post-Polio Association
Membership and Information Request Form