KYSAFF Membership Form

Yes! I want to become a member of the Kentucky Self-Advocates
For Freedom!
Please complete this application and mail it with payment to:

Chapter Name Membership List for

  

 

President:

  Vice-President:

Secretary:

     Treasurer:   

Offices information

President:

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

Vice President:

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

Secretary:

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

Treasurer:

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

Members following information

Name::

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

.Name::

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

Name::

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

Name::

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

Name::

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    

.Name::

  Birth Date: :

Address::

  

 Home Telephone:

  Cell Telephone:

E-Mail Address: 

    



Thank you for your application!