Cleveland Membership Application

Name:  

Address:

City:   State:   Zip Code:

Day Telephone:  Evening Telephone:   Cell Phone:

Email Address:   Birth Day/month:

Your interest in TRIO is because you are a:

Recipient  Candidate  Living Donor  Donor Family  Professional

 Support Person  Student Other

Type of Transplant:   Date:   Transplant Center:

Type of Transplant:   Date:   Transplant Center:

Type of Transplant:   Date:   Transplant Center:

Type of Transplant:   Date:   Transplant Center:

How Did You Hear About TRIO ?

Cleveland Clinic  University Hospitals  Akron General   St. Elizabeth   Friend 

 Health Fair  LifeBanc  MOTTEP    Other

Enclosed are my dues. One level per household of $20.00. This amount contributes 50% to the local treasury for routine budgetary matters and 50% to support the international headquarters to continue TRIO's mission of support, advocacy, education and awareness.  OR  Please award me a needs based grant for dues. I would like to become a member, but I cannot afford dues currently.

Which chapter are you interested in joining? Select One Greater Cleveland Chapter Mahoning Valley Chapter Renaissance Chapter (Toledo) Member at Large (via National Office) Akron Canton Chapter

Please make checks payable to: TRIO, and mail your payment to: 

TRIO, PO BOX 93163, Cleveland, Ohio 44101-5163

Please send me Green Ribbon Lapel Pins @ $2.00 each plus total $0.50 postage/handling.  The net proceeds from the Green Ribbon Lapel Pins support the TRIO Greater Cleveland Chapter's Scholarship Fund.