Printable Sign-up Form

Join the Lupus Foundation of America, Inc., Mid-South Chapter

Please print this form, fill out and mail check to:

Lupus Foundation of America, Inc., Mid-South Chapter
4004 Hillsboro Road, Suite 216-B
Nashville, TN 37215
 
   
Member Information

                   Name  __________________________________________________
       Address Line 1  __________________________________________________
       Address Line 2  __________________________________________________
                     City  __________________________________________________
                   State  _________________  Zip ________  
                  Phone  __________________________________________________
       E-Mail Address  __________________________________________________
Membership Options  ___  Patron ($100)                                  ___ Family ($25) 
                            ___  Sponsor ($50)                                  ___ Single ($20)
 
   
Payment by Check

Please make checks payable to: Lupus Foundation of America - Mid-South Chapter 
Check # ____________________
Amount  ____________________
   
Payment by Credit Card

Payments by credit card may be mailed or faxed (615) 292-0520 to the LFAM office:  
        Credit Card  __ Visa       __ Mastercard       __ American Express       __ Discover
                       

            Number  ___________________________________________________

            Name (as it appears on card)  ___________________________________________________
             

            Expiration Date  _____________/___________  mm/yy

            Card Verification Code ________________ (3 digit code on the back of your card) 
                       

            Amount  _________________________
   
Additional Information  

How did you hear about us? 

___  I/friend/family member have lupus
___  Through a support/community outreach event
___  Through the media
___  I attended a LFAM fundraiser
___  Other 
 
Are you interested in volunteering?  __ Yes __ No 
If, yes, please select areas of interest:
(choose all that apply)
 

____  Office Assistance         ____   Membership Drive
____  Education Services       ____   Communications/Publicity
____  Support/Outreach        ____   Volunteer Management
____  Fund Development        ____   Health Fair/Speaker's Bureau
 
   
Thank you for supporting your local chapter of the Lupus Foundation of America!