Wufoo

Membership/Renewal Membership Form

Please fill out this membership form and submit with payment to Lupus Foundation of America, Utah Chapter, Inc. Your membership will include our quarterly newsletter, Lupus Now Magazine(3 times a year), our monthly e-newsletter, and any educational information upon request.
**Paperless** Memberships will include our monthly e-newsletter and our quarterly newsletter in PDF form. You will still receive the Lupus Now Magazine unless you specifically request not to.
Email is required for paperless memberships.

Name * First Last
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Phone Number ### - ### - ####
Please choose one *
I have lupus I have a family member with lupus I have a friend/coworker with lupus
Age Group
Under 20 20's 30's 40's 50's 60+
Membership Type *
New Membership/Renewal Membership $25.00/year Complimentary Membership(6 months) **Paperless** New/Renewal Membership $25.00/year **Paperless**Complimentary Membership (6 months) Buy a "Someone You Know Has Lupus" Bracelets $1.00 each

To pay by check, make payable and mail to:
Lupus Foundation of America
Utah Chapter
455 E 500 S LL2
Salt Lake City, Utah 84111

To pay with credit card:
Make payment at Paypal.com to info@utahlupus.org
I would like to include a donation with my membership in honor or memory of
Donation Amount to be added to membership $ Dollars . Cents
Yes! I am interested in helping with:
Health Fairs Mailing Newsletter Publicity Fundraising Phoning Lupus Walk Office Help Outreach Board of Directors Other
Do Not Fill This Out