CHARGE Syndrome Foundation · Membership

One moment please...

Please JOIN or RENEW

Membership

*

$30 - Annual - Calendar Year

$250 - Lifetime Silver

$1,000 - Lifetime Gold

$5,000 - Lifetime Platinum

$10,000 - Lifetime Diamond

Membership Options

Name

*

First Name

Last Name

Email

*

Verify Email

*

What is your race?

*

American Indian or Alaskan Native

Asian

Black or African American

From Multiple Races

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

What is your ethnicity?

*

Hispanic or Latino

Not Hispanic or Latino

Prefer not to answer

Spouse First Name

Spouse Last Name

*

Spouse Email Address

If DIFFERENT from your own

Verify Email

Company/Organization (if applicable)

Occupation

Address

*

City

*

Zip/Postal Code

*

Country

*

Phone

Individual with CHARGE

Individual with CHARGE First Name

Individual with CHARGE Last Name

Individual with CHARGE Gender

Male

Female

Individual with CHARGE Date of Birth

(mm/dd/yyyy)

We greatly appreciate your membership. If you would like to make an extra donation, you will help fund additional research, outreach and advocacy.

Add 3% to my total amount to help cover the payment processing fees