New Member Form

Ventura County / West Valley Chapter
Transplant Recipients International Organization

Attendance to any TRIO meeting is free and open to the public. You may become a member of the Ventura County/West Valley Chapter of TRIO. Members receive newsletters and voting privileges in local elections. Dues is $10 per person annually which benefits TRIO's efforts in Organ/Tissue Donor Awareness events.

You may also decide to become a member of TRIO International, Washington, D.C. Dues is $10 per person annually. Members receive newsletters and voting privileges in national elections. Dues is $10 per person annually which supports the operations and efforts of the international office in Washington, D.C.

Membership to both organizations is $20 per person annually. Please complete the information below and click [Submit]. A member of the local chapter will contact you to complete your membership and give you instructions on how to pay your dues.

	First Name Last Name
	First Name Last Name
Company
Address
City:	State Zip Code
Country
e-mail:
Phone:	Home: Office:

Number of new members to the local TRIO chapter
Number of new members to the National TRIO Office
Total Annual Dues ($10 per membership)

Just to help us get to know you better, please answer this short survey.....

How were you referred to TRIO Ventura County/West Valley? (select as many below as appropriate)

Hospital/Doctor/Transplant Coordinator	Web Page
TRIO National or another TRIO Chapter	Movie Screen Ad
Friend or Relative	Utility Bill Insert
Another TRIO Member	Newspaper Article/Advertisement

What is your interest in Organ/Donor Awareness Issues? (select as many below as appropriate) This information is used only to allow us to determine the needs of our membership when inviting speakers to our meetings and planning events. This information will remain confidential and not shared with, or sold to, anyone.

	I am a patient awaiting a transplant heart lung liver kidney pancreas intestines other
	I am a transplant recipient, having received the gift of a heart lung liver kidney pancreas intestines other
	I am a caregiver/family member to a patient who is being evaluated for transplant/is waiting on the list/has been transplanted/is a living donor for: heart lung liver kidney pancreas intestines other
	I am a professional in the field of transplantation heart lung liver kidney pancreas intestines other
	I am being evaluated to be/am a Living Kidney Liver Lung Donor for a spouse parent child other relative friend stranger
	I am an advocate for Organ/Tissue Donor Awareness
	Other:

Thank you for your interest in TRIO and the importance of Organ Donor Awareness.

Remember, to make the decision to be an organ donor
is only the beginning of a miracle....

Share your decision to donate.

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