Date:

First Name:

Last Name:

Street Address:

Apartment or Suite:

City:

State:

Zip:

Home Phone:

() -

Work Phone:

() -

E-mail Address:

MEMBERSHIP WAIVER:

Resources for Independent Living (RIL) would like to use your photograph and/or name in our promotional material (newsletter, poster-board, etc.) Additionally, RIL would like to know if you are interested in sharing your phone number with volunteers via a phone tree.

I give RIL permission to publish my photograph, name, address and phone number, if so needed.

Current membership is valid June 1, 2009 through May 31, 2010