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YES! I would like to join the Brain Injury Association of Utah, Inc. and help in its work to provide advocacy and support for TBI.

Entry Membership is for brain injury survivors or family members unable to meet membership fee

Name:
Business:
Address:
City:
State:
Zip:
EMail:
Phone:
• Home:
• Work:
• Fax:
	New Member
	Renewal
Type of Membership:	Corporate - $200 Professional Membership - $50 Individual with Brain Injury or Family Member - $35 Friend of BIAU - $35 Entry Member - $5
Donation:	$
Total Enclosed:	$

Your dues include membership in the Brain Injury Association of America, which entitles you to a copy of their newsletter. One hundred percent of dues go directly to the Brain Injury Association of Utah. The funds will be used to provide services, materials, and printing costs.
or you can Print out this page and mail it to:

Brain Injury Association of Utah, Inc.
1800 South West Temple Suite 203
Salt Lake City, UT 84115

Payment can be made through by clicking one of the links below.

$200	$50	$35	$35	$5
Corporate	Professional Membership	Individual with Brain Injury or Family Member	Friend of BIAU	Entry Member