PWCF Membership Application

Prader-Willi California Foundation
(PWCF)

Membership Application

First Name:

Last Name:

Date:

Professional Title :

Organization:

Address:

Apt:

City:

State:

Zip +4:

Home Phone:

Work Phone :

Home Email:

Work Email :

Home Fax:

Work Fax :

Your relationship
to individual with
PWS:

	Parent/ Guardian		Sibling		Grandparent
	Aunt or Uncle		Family Friend		Supported Living Provider

Other:

Name of individual with PWS:

Birthdate:

Sex:

Male Female

Diagnosis Type:

	Deletion		UPD		Imprinting Mutation
	Translocation		Clinical

Other:

Regional Center Affiliation:

Your Professional Affiliations/Areas of
Interest/Expertise:

Language(s) Spoken Other Than English:

Are you a member of PWSA (USA)?	Yes No
	Please send me PWSA (USA) membership information

Sharing List:	You may share my name with other families for support and networking purposes	Yes No
	Please keep my name confidential, available only to PWCF officials	Yes No
	Please remove me from the mailing list	Yes No

Membership Categories		Annual Dues
Individual: Single Parent/Indiv. with PWS	(Entitles One Vote)	$25
Family: Parents/Primary Caregivers	(Entitles Two Votes)	$40
Professional: Physician/Provider/Associaton	(Entitles One Vote)	$55
Extended Family: Grandparent/Aunt/Uncle/Sibling	(No Voting Privileges)	$40
Family Friend	(No Voting Privileges)	$25
I/we cannot afford dues at the time but wish to become a PWCF member.
I have checked the box above to show the correct membership category.
Additional Donation*
to pay online or
to print and mail

*Prader-Willi California Foundation is a 501(c)(3) tax exempt charitable organization.
Membership dues are not tax deductible. Donations to PWCF are tax deductible as a charitable contribution. Your membership includes a subscription to the quarterly newsletter, PWCF News.

Prader-Willi California Foundation
514 N. Prospect Avenue, Suite 110-LL
Redondo Beach, CA 90277
(800) 400-9994 (CA only) • (310) 372-5053 • Fax (310) 372-4329
E-Mail: pwcf1@aol.com • Web: www.pwcf.org