GEORGIA PEACH COCHLEAR IMPLANT ASSOCIATION
P.O. Box 1172 Tucker, GA 30085-1172

MEMBERSHIP APPLICATION

JOIN US TODAY!

Dr/Mr/Mrs/Miss*
Address
City
State
Zip
Country
Phone
Fax
E-mail *
Cochlear Implant User	Yes No
Type of Device
New Membership	Yes No
Date Implanted
Annual dues: Family $15.00 Due: June 1st. yearly Please send completed form and check payable to GPCIA to above address.
Please send completed form and check payable to GPCIA to above address I authorize GPCIA to share this information with other Georgia Peach Association members as well as prospective cochlear implant candidates. I do not wish my address or other information above to be shared with anyone
Signed
Date

As a member of GPCIA, you are entitled to free and discounted rates to our events, such as our annual Holiday Party, Retreat, and picnic. GPCIA is a non-profit organization under tax code 501(c)(3); your membership fee and any donations to our organization are tax deductible.