Membership Please fill out and click Submit.Your Name(s): * First Last First Last Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountry Email * Would you like to be included on our mailing list? YesNo Phone All contributions are tax-deductible, and PFLAG welcomes matching grants from employers. Membership Level *Basic (single person) + Newsletter = $30/yearBasic (couple/family) + Newsletter = $40/yearNewsletter Only (non-voting member) = $20/year For anyone who finds this financial obligation burdensome, please contact the treasurer or one of our co-Presidents about having your dues wholly or partially waved. Any conversations will be held in the strictest confidence. Your membership and participation are most important to us. Member Information Please complete as much of this form as you feel comfortable with. Any information will be shared only with other members as needed (i.e., name and number will be given to a phone-tree coordinator unless you specify otherwise). I have a: sondaughterfamily memberfriend who is: gay/lesbianbisexualtransgendered I am: gaylesbianbisexualtransgenderednone of these apply Are you willing to provide your phone number to newcomers who may want to talk between meetings? *YesNo Are you willing to discuss any religious concerns you may have? YesNo If you answered Yes to the above, please tell us a little bit about your religious affiliation: Please describe any skills or training you may have that you can share with PFLAG to whatever extent you are able: I am willing to: Work on a committeeCo-ChairBring refreshments to a meetingVolunteer in other ways If you checked "Volunteer in other ways" above, please explain: Instructions Please send your check to: Nancy Fiore, Treasurer PO Box 4585 Wayne, NJ 07470 VerificationPlease enter any two digitsExample: 12This box is for spam protection - please leave it blank
