WCB New Membership Registration Form

New membership type *

Donate to offset PayPal fees charged to WCB

Join WCB as a Member at Large (no local chapter or affiliate)

Join local chapter(s)/special interest affiliate(s) below.

Special Interest Affiliates (statewide)

Guide Dog Users of Washington State $15 GDUWS

Washington Council of the Blind Diabetics $5 WCBD

NEW MEMBER INFORMATION

First Name *

Middle Name or Initial

Last Name *

Preferred Name

Address *

City *

State *

Zip *

Primary Phone Number *

Primary Phone Type *

Alternative Phone Number

Alternative Phone Type

ACB REQUIRED DATA

Over the age of 18? *

Birthdate (mm/dd/yyyy) *

Visual Status *

If visually impaired, are you legally blind?

Lifetime Member of ACB? *

ACB Braille Forum preference *

ACB mail preference *

Gender *

Ethnicity *

WCB Newsline preference *

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