Please provide your contact information below. We respect your privacy and will keep the information you provide confidential. We will use it internally to enhance services to members. In addition, we need some of this data for reporting to maintain our nonprofit status.
Name: ____________________________
Institution/Organization/Company:_________________
Street Address:___________________________
State and zip code:____________________
Country:___________________________
Email:_____________________________
Historical field of interest:________________________
Occupation:____________________________
For example: Advocate; Museum/Library; Student (undergraduate); Student (graduate); Teacher (junior high/middle school); Teacher (high school); Teacher (college/university); other.
For individuals, optional demographic data:
Date of birth______
Disability ____________
Ethnicity/Race _____________
Gender_____
One year membership 2006-2007
____ $15.00 – student or low income
____ $30.00 – individual
____ $100.00 – organizations
Please make check payable to Disability History Association
Send to:
The Disability History Association
Attn: Lee Pennington
2155 Scotts Crossing Court #302
Annapolis, MD 21401