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Membership/Renewal/Donation Form

Please fill out this membership/donation 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)

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
OR call 801-364-0366 to pay by phone
I would like to include/make a donation in honor or memory of
Donation amount $ 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

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