Membership Registration

PWSA of Ohio Membership

First Name * Last Name * Name of others in the family * Address Line 1 * Address Line 2 * City * State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Phone # * e-mail

Please check all that apply *

Parent Person diagnosed with PWS Family Member (i.e. Grandparent, Aunt, Brother, etc.) Friend Professional (Doctor, Therapist, Health Care Worker, Provider, DODD employee, etc.)

First name of person with PWS * Last name of person with PWS * Birth Date of individual with PWS

Male/Female

N/A Male Female

Does person with PWS live at above address YesNoN/A Address of individual with PWS / If living elsewhere Diagnosis of individual with PWS UnknownDeletionUPD (uniparental disomy)Translocation-ImprintingClinical

Membership Type *

Renewal New Newborn/Newly Diagnosed

Membership Level *

Hardship / Single or Family (1 year) ($0 USD) Single or Family Membership ( 1 year) ($20 USD) Lifetime Membership, Single/Family ($200 USD) Organization Membership (1 year / 1 Vote) ($30 USD) Lifetime Membership: Organization ($500 USD)

Can we include you in the main share list form members only Can we forward your information to PWSA(USA) Additional information you would like to share

Membership information

Additional Donation ($ USD)