The logo of SCINID

SPINAL CORD INJURY 
NETWORK INTERNATIONAL

Membership/Donation Form

Your donations and membership help keep our programs available.

Annual membership fees are $20. A check returned because of insufficient funds is subject to a $10 fee. Please make check payable to SCINI and send to:

SCINI is a not-for-profit 501(c)3 charitable organization #94-3037195. Donations are tax deductible according to state and federal law. SCINI receives no state or federal funding. SCINI administrative overhead is 0% of the total budget. All our services are made possible through donations.

 

Name (use format: Last, First): 

Street Address: 

City: 

State: 

Zip Code: 

Area Code/Phone: 

Age: 

Social Security No.: 

Date of Injury: 

Level of Injury: 

Cause of Injury: 

Rehab Hospital: 

To reset the form and start over, please click on the button below:

  Print this screen before hitting "Submit" to save your copy of what was sent.
Note:You will only see what shows up on the screen, but we will receive all of the text. To submit your form, please click on the button below:

 
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