FAMILY MEMBERSHIP APPLICATION FORM DATE_________________

PDF version of this form available by clicking here

I would like to become a member of The Alamo Area Parkinson’s Support Group of the American Parkinson Disease Association.
_________1 Year $24; ________2 Year $48

If you are a current member there will be a date after your name on the mailing label of this newsletter. That is the expiration date of your membership. If there is no date we are not carrying you as an active member.

We__do/do not___ authorize publication of my address/phone/email address in the membership list (Signature)________________________________? -

Name______________________________________-

Spouse____________________-

Mailing Address ____________________________ APT_______-

City____________________________ State ______? -

Zip Code+4 __ __ __ __ __ - __ __ __ __ -

Telephone (__ __ __) __ __ __ - __ __ __ __-

E-mail Address *______________________________-

E-mail the Newsletter and other information: ___YES ___NO

* Allowing us to email Support Group information, and our newsletter saves us a great deal of money that is needed for other purposes. Please consider it.-

Make Checks payable to AAPSG and mail to Joan Duval, Treasurer AAPSG, 8507 Chesham, San Antonio TX 78254