MEMBERSHIP & CHARITABLE CONTRIBUTION FORM
Annual Membership Dues: ___
New member ___ Renewal
All membership dues go into the General Fund.
Additional Tax Deductible Contribution: ___ $30 ___ $50 ___ $100 ___ other $________
additional contribution to ___ General Fund ___High School
___ Research ___Medical School Scholarship
*The General Fund supports the
daily activities of the organization.
*Become a Pillar of NJCFSA: Contribute $100 or more to the general fund.
*Contributions will be gratefully acknowledged in the NJCFSA newsletter unless requested otherwise.
Total Membership Fee and Charitable Contribution Enclosed……… $________
(Please note: members who request reduced dues must return this renewal form to continue membership. Please consider that we need your membership dues to continue to provide ongoing services and benefits to our members. Fill in amount paid above. Please indicate why you request reduced dues on the line below.)
Please Circle One: PATIENT SUSPECTED PATIENT FAMILY FRIEND OTHER__________
New Member (or changes to a current member’s) Information:
Name________________________________________________ Phone (____) ___________________
Address______________________________________________ County ________________________
City _____________________________________ State _______ Zip Code_______________________
Are you a member of a local NJCFSA support group? If so, which county? ____________________________
To join our Telephone Support Network so that you can speak with other members, please sign below.
Signature for Telephone Support Network
We need your help to keep NJCFSA running smoothly. Listed below are some volunteer opportunities. These can be one time commitments or longer if you are able to help more. Please check all the ways you would be interested in helping us.
_____ Board member of NJCFSA
_____Conference Committee Member
_____Write for newsletter
_____Help with mailings
_____Post posters and notices in your community
_____Advertise our conferences and other events
_____Ideas for fundraisers
_____Help with fundraisers
_____Find corporate sponsors for our conferences and other programs
_____Lead a support group in your area
_____Begin an informal phone support group
_____Other: Please explain __________________________________________________________
Please send form and dues to:
P.O. Box 477
Florham Park, NJ 07932
Phone 888-835-3677 – http://njcfsa.org