Membership in the
Association for Glycogen Storage Disease

Print out this sheet, fill it in, and mail to the AGSD Treasurer along with your dues.

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AGSD Membership and Dues Sheet

Please, print or type:

Name _____________________________________________
Address ____________________________________________
City, State, Zip+4 ______________________________________
(Area Code) Phone Number (_______)________________________
E-mail address ________________________________________
Name of person with GSD _________________________________
Relationship to person with GSD _____________________________
Their GSD type ________ Please list their birthdate as ______________

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  Checks must be payable to: Association for Glycogen Storage Disease
   ONLY U.S. FUNDS CAN BE ACCEPTED.
   Our banking institution will only give full value on a BANK MONEY ORDER

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 Yes  No  I/we give permission to use my/our name(s) on the appropriate list:
 (please circle your involvement)   parent   self    professional   relational

*All dues for membership expire on December 31*

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URL: www.agsdus.org  Web site last updated on December 18, 2011.
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