Injury Free Coalition for Kids
Membership Application

Use this form to apply for Organization or Individual Membership.
Remember to mail your applicable dues payment to the address below.

First Name:    Last Name:
Your Title:    Degrees:
Organization:
Address:
City/State/Zip:
Phone:    Cell Phone:
Fax:
E-mail:

Membership Level

Select the appropriate membership level from the list below:

Organization Membership, Sponsor ($50,000)

Organization Membership, Community Champion ($25,000)

Organization Membership, Partner ($10,000)

Organization Membership, Advocate ($5000)

Organization Membership, Supporter ($2500)

Organization Membership, Friend ($250)

Individual Membership ($500)

Verification

(Submission can take a few seconds, please be patient...)

Membership dues payment: Please make your check payable to the Trustees of Columbia University in the City of New York, and send by mail to:

Injury Free Coalition for Kids
Attn: Barbara Barlow, MD
PO Box 580
Tenafly, NJ 07670