Membership Application

Application Date (mm/dd/yyyy format required)

Your Name (required)

Your Address (required)

Your City, State & Zip

Your Email (required)

Your Home Phone

Your Cell Phone

Your Message

MEMBERSHIP WAIVER: (required)

Resources for Independent Living (RIL) would like to use your
photograph and/or name in our promotional material (newsletter,
poster-board, etc.) Additionally, RIL would like to know if you are
interested in sharing your phone number with volunteers via a
phone tree.
I give RIL permission to publish my photograph, name, address and phone number, if so needed.

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