Membership Signup - Lowe Syndrome Association

Full Name*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

I am joining the LSA because I am a...*

Please use the drop-down to choose an option.

If Friend or Relative, List Family to Which Connected

Primary Language Spoken In Your Home*

I Would Like Someone from the LSA to Contact me

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No

Additional Contacts

Add an Additional Contact

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

For LS Parents

My Child was Recently Diagnosed with Lowe syndrome

Yes
No

LS Child's Name

LS Child's Birthday

Second LS Child's Name

Second LS Child's Birthday

I give the LSA permission to provide name and contact info to approved researchers.

Yes
No

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I give the LSA permission to provide name and contact info to approved researchers.

Yes
No

I Have Completed a Patient Registry for my Child

Yes
No

I Would Like More Information about LSA's Patient Registry

Yes
No

I Wish to be Added to a Parent Directory and give Permission to Share my Name, Address, and Email Address

Yes
No

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Membership Level

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Complimentary

$0 PER YEAR

I am a parent/caregiver or individual with   LS unable to make a contribution at this   time

Digital emails, newsletters, & notifications

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Adult With LS

$10 PER YEAR

For adults NOT living in their parents home

Digital emails, newsletters, & notifications

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Standard Membership

$35 PER YEAR

Digital emails, newsletters, & notifications

New member welcome Kit

Printed newsletter (mailed)

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Deluxe Membership

$100 PER YEAR

Digital emails, newsletters, & notifications

New member welcome Kit

Printed newsletter (mailed)

10% discount on LSA conference fees (for immediate family members only)

Select

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Friend Of The LSA

$500 PER YEAR

Digital emails, newsletters, & notifications

New member welcome Kit

Printed newsletter (mailed)

10% discount on LSA conference fees (for immediate family members only)

10% discount on merchandise sold at the LSA conference, if attended.

Select

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Membership Level*

Complimentary
Adult With LS
Standard Membership
Deluxe Membership
Friend Of The LSA
Other (Fill in below)

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I would like to make a donation to the LSA today.

We Appreciate Your Donation to the LSA!

Note: donations are not required to join the LSA.

Total

$0.00

Credit Card

Card Details

Cardholder Name

Membership

Basic Info

Membership

Additional Contacts

For LS Parents

Membership Level

Complimentary

$0 PER YEAR

I am a parent/caregiver or individual with LS unable to make a contribution at this time Digital emails, newsletters, & notifications

Adult With LS

$10 PER YEAR

For adults NOT living in their parents home Digital emails, newsletters, & notifications

Standard Membership

$35 PER YEAR

Digital emails, newsletters, & notifications New member welcome Kit Printed newsletter (mailed)

Deluxe Membership

$100 PER YEAR

Digital emails, newsletters, & notifications New member welcome Kit Printed newsletter (mailed) 10% discount on LSA conference fees (for immediate family members only)

Friend Of The LSA

$500 PER YEAR

Digital emails, newsletters, & notifications New member welcome Kit Printed newsletter (mailed) 10% discount on LSA conference fees (for immediate family members only) 10% discount on merchandise sold at the LSA conference, if attended.

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I am a parent/caregiver or individual with   LS unable to make a contribution at this   time

Digital emails, newsletters, & notifications

For adults NOT living in their parents home

Digital emails, newsletters, & notifications

Digital emails, newsletters, & notifications

New member welcome Kit

Printed newsletter (mailed)

Digital emails, newsletters, & notifications

New member welcome Kit

Printed newsletter (mailed)

10% discount on LSA conference fees (for immediate family members only)

Digital emails, newsletters, & notifications

New member welcome Kit

Printed newsletter (mailed)

10% discount on LSA conference fees (for immediate family members only)

10% discount on merchandise sold at the LSA conference, if attended.