Join the Lupus Foundation of America,
Mid-South Chapter

Please print this form, fill out and mail check to:

Lupus Foundation - Mid-South Chapter
4004 Hillsboro Road, Suite 216-B
Nashville, TN 37215
   
Member Information
Name
Address Line 1
Address Line 2
City
State
 Zip
Phone
E-Mail Address
Membership Options
Patron ($100) Family ($25)
Sponsor ($50) Single ($20)
   
Payment by Check
Please make checks payable to: Lupus Foundation - Mid-South Chapter
Check #
Amount
   
Payment by Credit Card
Payments by credit card may be mailed or faxed (615) 292-0520 to the LFAM office:
Credit Card
 Visa Mastercard American Express Discover
Number
Name
(as it appears on card)
Expiration Date
 / mm/yy
Amount
   
Additional Information  
How did you hear about us?

I/friend/family member have lupus
Through a support/community outreach event
Through the media
I attended a LFAM fundraiser
Other

Are you interested in volunteering?
 Yes No

If, yes, please select areas of interest:
(choose all that apply)
Office Assistance Membership Drive
Education Services Communications/Publicity
Support/Outreach Volunteer Management
Fund Development Health Fair/Speaker's Bureau
   
Thank you for supporting your local chapter of the Lupus Foundation of America!