HEIGHTENED INDEPENDENCE AND PROGRESS

Membership Enrollment Form

 

I am interested in joining in the work of Heightened Independence and Progress.
I am a new____ (or) ____ renewing member for the 2016 year.

 

Name

 

Street/Apt.#

 

City/State/Zip

 

Phone: please specify day, evening, or both

 

 

 

Membership Categories -- please check the right category for you:

 

 

Basic Member

$15.00

 

 

Contributing Member (for those who want to give
"that extra something" to support hip)

$30.00

 

 

Family Membership (including consumer with a disability
who is the voting member)

$20.00

 

 

Student or Teen Member*

$ 5.00

 

 

Corporate Member (includes non-profit and for-profit
agencies, businesses, and foundations)

$50.00

 

 

Life Member**

$500.00 and above

 

 

I am including an additional voluntary contribution of

$

 

 

 

Enclosed is my total remittance (check preferred, payable to hip).

 

 

* Students/Teens: Students of any age qualify. Please indicate the name of the school you are attending ______________________________

**Life Membership: A special category for those who wish to make a significant financial contribution to the advancement of independent living, for themselves, in honor of a family member or friend, or simply to show their desire to help all persons with disabilities in their effort to lead productive, independent lives.

 Contributions to Heightened Independence and Progress are tax-deductible.

hip       131 Main Street, Suite 120       Hackensack, NJ 07601
201-996-9100 (voice) 201-996-9424 (TDD) 201-996-9422 (fax)