| First Name: _______________________________ Last Name: _______________________ |
| Primary Occupation: _________________________________________________________ |
| Position Title: _______________________________________________________________ |
| Business: __________________________________________________________________ |
| Home Address: ______________________________________________________________ |
| City/State/Zip:________________________________________________________________ |
| Business Phone: (_____) ________-__________ Home Phone: (_____) _______ - ________ |
| E-Mail Address:______________________________________________________________ |
| Type of Membership: NEW______ RENEW______ (all contributions are tax deductible) |
Method of Payment: __ Check __ Money Order __ Credit Card
(Membership dues must be paid in U.S. currency) |
| __Family ($50) |
__Institutional ($200) |
| __Supporting ($75) |
__Century Club-personal ($1,000) |
| __Donor ($100) |
__Century Club-corporate ($1,500) |
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| If this is a gift membership, name and address of Donor:_______________________________________________________________________________ |
| _______________________________________________________________________________ |
Type of growth/growth hormone that interests you:________________________________________
_______________________________________________________________________________ |
| Optional: Your doctor's name and address:________________________________________________________________________ |
| _______________________________________________________________________________ |
| Optional: Child's Name:______________________________________ DOB:__________________ |
| Optional:Diagnosis: _______________________________________________________________ |
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A. CHECK OR MONEY ORDER
Please make check or money order payable to: "Human Growth Foundation"
Mail check or money order with the completed print version of Print Friendly Membership Application, or completed pen and ink applicastion (page) to:
Human Growth Foundation
997 Glen Cove Avenue # 5
Glen Head, N.Y. 11545
B. PAYPAL OR CREDIT CARD VIA PAYPAL
It's fast, free and secure!
You can pay with PayPal or with a credit card through PayPal. All major credit cards are accepted. A PayPal account is not required.
Simply select a Membership type from the dropdown below and click on the "Pay Now" button for access to the PayPal and credit card options.
If you are using a credit card option, click on "Continue" hyperlink on the right side of the page adjacent to the PayPal option; and follow the instructions.
NOTE: All but the Century Club memberships dues have increased in price. This is the first increase in membership dues in more than 12 years!
If you have any difficulty, with executing online payment, please contact the Webmaster
The Human Growth Foundation helps children and adults with disorders related to growth and growth hormone through education, research, support, and advocacy. Your tax deductible membership fee will help sustain the activities and programs supported by the Foundation.
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