Disability History Association: Membership/Renewal Application

Please print and then fill out this form.

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.

______ New Member

______ Renewing Member

Name: _________________________________________

Institution/Organization/Company:___________________________________________

Street Address:_______________________________________________________________

City/State/ Zip (Postal)Code:_______________________________________________

Country:__________________________________________

Email:____________________________________________

Historical field of interest:_________________________________________________

Occupation:____________________________________________________________

For example: Advocate; Museum/Library; Student (undergraduate); Student (graduate); Teacher (K-12); Teacher (college/university); Other.

For individuals, optional demographic data:

Date of Birth_________________________

Disability ___________________________

Ethnicity/Race _______________________

Gender_____________________________

Category of Membership:

______ $15.00 — Student or Low Income

______ $30.00 — Individual

______ $100.00 — Organizations

______ $1000.00 –- Lifetime Membership

Please make check payable to Disability History Association

Send to:

Philip Ferguson

College of Educational Studies

Chapman University

One University Drive

Orange, CA 92868

USA

For questions about membership and dues, please contact Phil Ferguson, DHA Treasurer, at pferguson@chapman.edu