Annual Membership Dues:              ___ New member   ___ Renewal                $     30.00
                                            All membership dues go into the General Fund.
Tax Deductible Contribution:   ___ $30  ___ $50  ___ $100 ___ other                    $________

Apply my additional contribution to       ___ General Fund             ___High School Scholarship
                                                            ___ Research                    ___Medical School Scholarship 

*The General Fund supports the daily activities of the organization.
*Become a Pillar of NJCFSA: Contribute $100 or more to the general fund.
*Contributions will be gratefully acknowledged in the NJCFSA newsletter unless requested otherwise.

                         Total Membership Fee and Charitable Contribution Enclosed………       $________

(Please note: members who request reduced dues must return this renewal form to continue membership. Please consider that we need your membership dues to continue to provide ongoing services and benefits to our members. Fill in amount paid above. Please indicate why you request reduced dues on the line below.)


 Member Information:

 Please Circle One:   PATIENT    SUSPECTED PATIENT    FAMILY    FRIEND    OTHER__________

 New Member (or changes to a current member’s) Information:

 Name________________________________________________      Phone (____) ___________________

 Address______________________________________________      County ________________________

 City _____________________________________  State _______    Zip Code_______________________

 Email ___________________________

Are you a member of a local NJCFSA support group?  If so, which county? ____________________________

 To join our Telephone Support Network so that you can speak with other members, please sign below.

Signature for Telephone Support Network



We need your help to keep NJCFSA running smoothly.  Listed below are some volunteer opportunities. These can be one time commitments or longer if you are able to help more.  Please check all the ways you would be interested in helping us.

 _____ Board member of NJCFSA

 _____Coordinate Volunteers

 _____Conference Coordinator

 _____Conference Committee Member

 _____Coordinate Newsletter

 _____Write for newsletter

 _____Help with mailings

 _____Post posters and notices in your community

 _____Advertise our conferences and other events

 _____Ideas for fundraisers

 _____Help with fundraisers

 _____Find corporate sponsors for our conferences and other programs

 _____Grant writing

 _____Lead a support group in your area

 _____Begin an informal phone support group

 _____Other: Please explain __________________________________________________________



 Please send form and dues to:

P.O. Box 477
Florham Park, NJ 07932

Phone 888-835-3677 –