Macular Disease Foundation

Macular Disease Foundation,
P. O. Box 55004, Va Beach, VA 23471

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Membership Application

There are three classes of membership, each with the same rights and privileges. Please check the membership you desire.

We currently do not accept credit cards for membership, so please, fill out the information below then print the page out for mailing to our address above! Please make your check out to "Macular Disease Foundation"

Individual Membership ($12 annual dues)
Contributing Membership ($25 annual dues)
Organization Membership ($50 annual dues)

Name:
Mailing Address:
City:
State:
Zip:
Phone Number:
Email Address:

Do you have a visual impairment?
Yes
No

Would you be willing to work as a volunteer for the Macular Disease Foundation?
Yes
No

Click here to print this page for mailing with a check, or

  
If you send us the information, we will still need your check to be mailed. Thank You!