Membership Form

(Please fill out all fields)

Date:	Thursday the 3rd of July 2008
First Name:
Last Name:
Address1:
Address2:
City:
State:
Zip:
Phone:
Fax:
Email:
DISABLED NON-DISABLED
If Disabled, give brief description: (mobility, wheelchair-user, part time/full time; vision; hearing) If Disabled, Enter Brief Description.
Do you use a Service Dog? Yes NO Name:
Donation:	appreciated, but not required (by mail)
Please tell us how or from whom you heard about "Kansas Disability Coalition" (If from the Internet, please tell us the site):

Kansas Disability Coalition | 5700 Hanover | Bel Aire, KS. 67220
wheeln1@cox.net

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