MEMBERSHIP LEVELS

Membership in The Presumed Consent Foundation, Inc. offers you state and national advocacy through representation with various governmental and health agencies, voting privileges, and a subscription to the quarterly Presumed Consent Foundation Newsletter.

All annual membership levels include a cap, t-shirt, and an ongoing supply of educational and advocacy materials such as our brochure and placards.

Transplant Recipients, Transplant Candidates, or Caregiver $25*

Additional family member in same household add $10

General Membership $60

Supporting $85

Contributing $ 150-500

Premier over $500

Health Care Professionals $60

* If this membership fee presents a hardship for transplant recipients or candidates, please contact us toll free at 866-706-9828 to discuss your options.

The Presumed Consent Foundation, Inc. is a tax exempt non-profit corporation under Section 501(c)3 of the Internal Revenue Code.

First class mailing of the newsletter, add $15 per membership.

To mail the newsletter to a country other than the US or Canada, add $1.00

Checks payable to The Presumed Consent Foundation, Inc:

Check # _________ Total Enclosed $___________

CREDIT CARD PAYMENT:

Credit Card: ___ Visa ___ MasterCard Total Enclosed $___________

Card Number: _______________________________________________

Expires: Card Verification Value: (three-digit number on signature line)_____

Cardholder’s signature (must be signed by cardholder)_________________________

Name imprinted on credit card_____________________________________________

Mail to:

The Presumed Consent Foundation, Inc

PO Box 58

Plainview, TX 79073-0058

MEMBERSHIP INFORMATION

Application Date ______________ New Member ___: Renewal ___ (Membership extends one year from this date)

To provide you with accurate information, please check the boxes that apply:

Transplant Recipient___Transplant Candidate___Caregiver/Spouse___Relative___

Name ______________________________________

Address_____________________________________

City________________________________________

State _______________________________________

Zip _______ Country ___________

Telephone (home) _________________

Telephone (work)__________________

E-mail ______________________________________________________________

Congressional District ___________________________ State__________________

____I authorize the release of my name, address and telephone number to other transplant patients for the sole purpose of support. This information will not be used for any other purpose and is never shared or sold.

Optional information for Transplant Recipients and Candidates:

Doctor’s name:_____________________________________________________

Division___________________________________________________________

Clinic/Hospital______________________________________________________

Address___________________________________________________________

List other family members, or if you are able to share a gift of membership for another

Transplant Recipient or Candidate

Name ________________________________________

Relationship __________________________________

Address ______________________________________ Telephone(Home)_________

City _________________________________________ Telephone(work)__________

State ___________ Zip _______ Country _________