Disability History Association: Printable Membership/Renewal Application

Please print and then fill out this form.

We respect your privacy and will keep the information you provide confidential. We will use it internally to enhance services to members. In addition, we need some of this data for reporting to maintain our nonprofit status.

______ New Member
______ Renewing Member

Name: _________________________________________

Institution/Organization/Company:_____________________________________________

Street Address:_____________________________________________________

____________________________________________________________________

State and Zip Code:_______________________________

Country:__________________________________________

Email:____________________________________________

Historical field of interest:_________________________________________________

______________________________________________________________________________

Occupation:___________________________________________________________________
For example: Advocate; Museum/Library; Student (undergraduate); Student (graduate); Teacher (junior high/middle school); Teacher (high school); Teacher (college/university); other.

For individuals, optional demographic data:

Date of Birth_________________________

Disability ___________________________

Ethnicity/Race _______________________

Gender________________________________

Category of Membership:

______ $15.00—Student or Low Income
______ $30.00—Individual
______ $100.00—Organizations

Please make check payable to Disability History Association

Send to:

Sandy Sufian, PhD, MPH
Department of Medical Education
808 South Wood St, 9th Floor
College of Medicine East, MC 591
UIC School of Medicine
Chicago, IL 60612

For questions about membership and dues, please contact Sandy Sufian, DHA Treasurer, at sufians@uic.edu, or Audra Jennings, DHA Secretary, at jennings.160@osu.edu.