Submit for Adult Independence Fund

Name of adult with SB *

First Name

Last Name

Birthday Shout Out *

We are doing social media birthday announcements for our members with spina bifida that include a photo and brief bio (first name, age, city of residence, hobbies and interests). We will email you prior to the month of the birth date to collect this information.

Yes, please email me for a birthday shout out and I give SBWIS permission to use the photo and information I provide on social media to acknowledge this birthday.

No thank you.

Home mailing address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of person/place you would like the check made out to: *

This can be yourself, a parent, trusted friend, bank, credit card company, landlord or any 3rd party for direct payment. It is your responsibility to verify that they will accept payment from SBWIS. 3rd party checks will not be re-issued if lost.

First Name

Last Name

How do you keep in touch with SBWIS? *

Checking the website

Following Facebook posts

Newsletter postcard

Email blasts