Content-length: 6194 Content-Type: text/html; charset=UTF-8 Membership Application
JDF Membership Application


DONOR AND GIFT INFORMATION

Within the US, you can become a member of JDF for US$25 or more. Outside the United States, you can receive COUNTDOWN magazine for US$30. And remember: Your membership gifts fund vital diabetes research! 

(please print)          

Donor information:

_______________________________        To give a gift membership, please 
Last Name/First Name/Middle Initial    complete this section also.
________________________________       ____________________________________
Address                                Recipient's Name
________________________________       _____________________________________
City/State/Zip                         Address
________________________________       _____________________________________
Area Code + Home and Business Phone    City/State/Zip	
_________________________________      _____________________________________
Date of Birth                          Recipient's Date of Birth

[] Renewal Membership  [] New Membership  
[] Special Contribution (non-membership) 

Please send a medical emergency card for:
          [] Adult  [] Child

Does any member of your family have diabetes?
[] Husband   [] Wife  [] Self   [] Child   [] Other __________          A505

PAYMENT INFORMATION

                                                                                                 
My check for US$__________is enclosed and made payable 
to Juvenile Diabetes Foundation.

__________________________________  _______________________________________
Credit Card Number Expiration Date  US$ Amount

                                    _______________________________________
Charge my membership donation to:   Card Holder’s Signature
         
[] VISA  []  MasterCard  [] Amex  [] DISCOVER

Continued research may prevent, even eliminate, diabetes altogether. Help us find the cure now! Please be as generous as you can. Just print out this form, fill it out, enclose it with your contribution and mail it to: Juvenile Diabetes Foundation International, The Diabetes Research Foundation, PO Box 5050, Sterling, VA 20167-9050.

There is a cure, and together we'll find it! Thank you!

Return to Benefits of Membership

Copyright © 1996 Juvenile Diabetes Foundation International. ALL RIGHTS RESERVED.
The BETA SOCIETY, COUNTDOWN, CREATING A WORLD WITHOUT DIABETES, THE DIABETES RESEARCH FOUNDATION, JDF, JUVENILE DIABETES FOUNDATION INTERNATIONAL, THE ONLY REMEDY IS A CURE, WALK FOR THE CURE, 1-800-JDF-CURE and 1-800-WALK-JDF are Trademarks and Service marks of the Juvenile Diabetes Foundation International.
E-mail comments to info@jdfcure.com
Juvenile Diabetes Foundation
The Diabetes Research Foundation
120 Wall Street
New York, NY 10005-4001
800-JDF-CURE
212-785-9500
Fax 212-785-9595