Annual Membership:	____ New	____ Renewal
 
Membership Category:      ___ Individual / Family      $  20
            ___ Friend      $ 50             ___ Contributor      $  100
            ___ Sponsor     $500             ___ Benefactor       $1,000
 
I am a:	____ Patient	____ Family Member	____ Friend
	____ Professional (field:_____________________________)
 
In Honor / Memory of __________________________________________________
 
Name: 		_______________________________________________________
 
Address: 	_______________________________________________________
 
City/State/Zip	_______________________________________________________
 
Phone		Home:	_________________	Work: _________________

Email:       _______________________________________________
 
Parent or relative of a child with Niemann-Pick	Type    A   B   C   D	(Circle one)
 
Names of NP Children	_______________________________________	DOB____________
 
			_______________________________________	DOB____________
 
			_______________________________________	DOB____________
 
Where Child(ren) was diagnosed:
Diagnostic Center	_______________________________________________________
 
Address			_______________________________________________________
 
City / State		_______________________________________________________

Age at Diagnosis	________________________
 
Names of Non-NP		_______________________________________	DOB____________
Children
			_______________________________________	DOB____________
 
			_______________________________________	DOB____________
 
Do you consent to your name and address being disclosed to
other parents of children with Niemann-Pick?	Yes	No
 
Would you like to receive the Newsletter?	Yes	No
 
Signature: _______________________________________________	Date: ___________