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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