American Parkinson Disease Association
Nebraska Chapter
Membership Registration
Name(s): ______________________________ Date: _____________
Address: _________________________________________________
City: ______________________________ State: _______ Zip: _____
Email: __________________________Telephone: ________________
Cell Phone: ________________ Work Phone: ____________________
___ Patient ___ Family ___ Caregiver ___ Friend ___ Medical Professional
Membership Fees: $15 per individual/ $30 per family
___ I've enclosed a check made out to Nebraska Chapter APDA for a
___ single/ ___ family membership.
Signature _________________________________________________
Membership Benefits:
Ø Receive the newsletter, advocacy notices, research updates and other educational materials.
Ø Obtain prior notification of upcoming educational programs and events.
Ø Become an essential partner in fundraisers to help raise awareness and education in Nebraska.
Ø Attend the annual meeting in October to elect officers and vote on important issues.
Ø Opportunity to be on the Board of Directors for the Nebraska Chapter APDA.
Preferred Method of Contact: ___ Mail ___ Email/Internet
Would you be willing to volunteer your skills, time and other resources to the Chapter, Information & Referral Center and/or support group in your area?
___ Leadership/Board membership ___ Fundraising/Special Events
___ Special Mailings
___ Symposium/Conference Assistant ___ Computer Data Entry
___ Newsletter Labeling
___ Public Relations/Marketing ___ Phone Duties ___ Advocacy
___ Desktop Publishing ___ Writing Thank You Notes ___Solicit Donations
___ Other: ____________________________________________________
Mail completed form to Nebraska Chapter APDA, 501 N. 87th Street, Suite 207, Omaha, NE 68114