Membership Application

The Greater New York Chapter of the National Spinal Cord Injury Association (NYCSCIA) is pleased to
extend a free membership to persons with spinal cord injury or disease.

BENEFITS INCLUDE:

• Subscription to the NSCIA quarterly magazine SCI Life
• PVA Resource Guide, Priority to Peer Mentor Network
• Monthly Electronic Newsletter
• Access to the National SCI Hotline
• Access to the National Resource Center’s Library
• Discounts and early notification of NSCIA conventions and conferences
• Plus much more…

Please complete this form

Fields with an * are required.
*First Name:
*Last Name:
*Address
Organization
Telephone Number (Home)
Telephone Number (Work or Cell)
*E-mail Address
If you are Spinal Cord Injured
Level of Injury
Date Injured
Age When Injured
Date of Birth:	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Rehab. Hospital Attended
For more information please call 212-659-9369 or email NYCspinal@NYCspinal.org.

© 2010 Greater New York Chapter of the National Spinal Cord Injury Association – All rights reserved.
NYCspinal@NYCspinal.org