Grandparent Membership Form

Grandparent Membership Form

 

Family Member Name
Phone Number
Address
City
State
Zip
Email
Please note that by submitting this application you agree to be charged $50
Father's Name
Father's Occupation
Work Phone
Mother's Name
Mother's Occupation
Mother's Work Phone
Name of Special Child
Child's Date of Birth
Child's Gender
Does he/she attend school?
Name of School
Address of School (type full address)
When was your Child Diagnosed?
Who made the diagnosis?
Please Include the names and birthdates for all other children in the household
Child 1 Name
Child 1 Birthdate
Child 2 Name
Child 2 Birthdate
Child 3 Name
Child 3 Birthdate
Child 4 Name
Child 4 Birthdate
Child 5 Name
Child 5 Birthdate
Please check the following areas of interest:
Does your company have a matching gifts program?
Would your company be interested in sponsoring an activity?
Would your company be interested in advertising in our newsletter?
Would your company donate goods or services to NYFAC?
Would you be willing to volunteer sometime to help NYFAC?
*Please note that by clicking submit, you agree to paying $50 per year for registration with NYFAC.*

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