Brain Injury Association of Arkansas

Membership Application

We Need You To Join Our Team!

A team that works to:
            ∙   improve the quality of life for individuals with brain injury and their families, and
            ∙   develop and support programs to prevent brain injuries.

If you would like to become a member of the Brain Injury Association of Arkansas, please complete and submit the information below.  Membership will become effective when your dues are received.

Thank you for your interest,

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Use the <Enter> key or the [Submit Form] button to send.

Please click the [Submit Form] button when you're finished.
    New Membership,    Membership Renewal
Name:   BI Survivor?
Address:
City:
State:
Zip:
Home Phone: Please include Area Code.
Cell Phone:
Work Phone:
Fax:
Primary Email:
Other Emails:
Occupation:
Employer:
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Primary Mail: Home Work
  Please send the BIA-AR newsletter by:
  Please send membership renewal by:

Membership Categories:

Annual membership dues are shown
(see bottom of page for benefits)
  Individual/Family ($35)
     Survivor & relationship: 
Student Member ($20)
Professional Member - Individual  ($75)
Friends of the Association  ($200) *
Silver Member ($500) *
Gold - Brain Trust Member  ($5,000) *
Platinum - President's Circle Member  ($10,000) *
 Special Rate Member **
*

Please note: If applying for an Organization/Institution Membership,
please provide a contact name in the Comments field.
** A Reduced Rate is available for those persons with a brain injury who are on limited incomes. The fee will help us process your application as well as help cover the cost of mailing materials. Benefits are the same as the Individual Member. Membership will not be denied to anyone based on their ability to pay.
Comments:
Payment Method:

After you click the [Submit Form] button, you will be taken to a page where you will be able to pay using PayPal.

If paying by check, print this page and mail with check (payable to BIA-AR) to:

          Brain Injury Association of Arkansas
          PO Box 26236
          Little Rock AR 72221-6236

(After you print a copy, click the [Submit Form] button.

Brain Injury Association of Arkansas
Annual Membership Dues & Benefits

Individual/Family Member:
$35

For individuals with brain injury, family members, or other interested individuals that are not professionals working in the field of brain injury

  • Quarterly National Association Newsletter: The Challenge

  • Discounted subscription rate to the Journal of Head Trauma Rehabilitation (JHTR)

  • Ongoing State Association informational newsletters and updates

  • Reduced rate for attendance at Association conferences and educational programs

  • Eligible to apply for conference scholarships or family support funds

  • Special Rate: $5 - $34 Reduced rate for individuals with brain injury on limited incomes. Same benefits as the Individual Member

Student Member:
$20

For students majoring in a profession related to the field of brain injury

  • Same benefits as the Individual Member

Professional Member:
$75

For individual professionals working in the field of brain injury or other interested professionals (Also for BIA-AR Board Members)

  • Includes all benefits of Individual Member

  • Preferred status for professional speakers at State Association conferences and educational programs
Friends of the Association:
$200

For individuals, families, friends, organizations, providers, institutions, and businesses

  • Includes all benefits of Professional Member

  • Listing in all State Association newsletters, conference programs, and annual reports

  • Reduced conference rate for up to 4 individuals at the Annual Conference

Silver Member:
$500

For individuals, families, organizations, agencies, institutions, providers, and businesses

  • Includes all benefits of Professional Member

  • Listing in all State Association newsletters, conference programs, and annual reports

  • Reduced conference rate for up to 4 individuals at the Annual Conference

  • Opportunity to offer complimentary one-year introductory membership in the Association for individuals and families served by the Organization/Institution

  • Complimentary eighth-page business card-size ad, or credit toward larger ad in all State Association quarterly newsletters and Annual Conference program

Gold - Brain Trust Member:
$5,000

For individuals, families, organizations, agencies, institutions, providers, and businesses

  • Includes all benefits of the Silver Member

  • Upgrade to complimentary half-page ad, or credit toward larger ad, in all State Association newsletters and Annual Conference program

  • Invitation to special receptions with Annual Conference Keynote Speaker

  • Special recognition at Annual Conference

Platinum - President’s Circle Member:
$10,000

For individuals, families, organizations, agencies, institutions, providers, and businesses

  • Includes all benefits of Gold - Brain Trust Member

  • Upgrade to complimentary full-page ad in all State Association newsletters and Annual Conference program

  • Complimentary exhibit space at all State Association conferences where exhibit space is offered

Last updated 01/30/10 12.00 pm