American Nystagmus Network - Membership Form

Home Contact ANN Site Map Search ANN Site

To register and pay online click here
To make an online donation only click here

ANN Membership Form

This form may be printed and used as a membership enrollment form. ANN, Inc. asks that you mail the form with a check or Money Order. Please DO NOT mail cash. Please also consider filling out the optional questionnaire, which follows the membership form on this page.

New Member / Renewal (circle one)

Mr. / Mrs. / Ms./ Other ______ (circle one)

First Name:____________________

Last Name:____________________________

Address:______________________________

City ________________________

State _______ Zip ____________

Country _____________________

Phone: ___________________________________________

Facsimile:_________________________________________

E-mail:___________________________________________

Payment Enclosed (select one)

____ Regular Membership - $25

____ Family Membership - $45

____ Lifetime Membership - $250+

____ Optional Donation $_______

Please make check or money orders payable to the American Nystagmus Network, Inc. All monetary values are stated in US dollars.

Mail to:

American Nystagmus Network, Inc.
303-D Beltline Place, #321
Decatur, Alabama 35603
Attn: Membership

ANN Questionnaire

ANN collects information to assist in service delivery to its members and to provide data and contact information to the medical community. Kindly complete the questionnaire and include it with your completed membership form. This questionnaire is optional.

Date of Birth: _____________

Relationship to Nystagmus:

____ Individual with Nystagmus

____ Parent

____ Other Family member

____ Health Care Professional

____ Medical Researcher

____ Social Worker

____Other, please explain: __________________________________________________

How did you find out about ANN, Inc.?

____Internet

____Another Individual

____Another Organization (Name:_____________________________________________)

____ Radio, TV, Newspaper

____Other, please describe: __________________________________________________

To the best of your understanding, what type of nystagmus do you have?

_____________________________________

May ANN, Inc. give your name and addresses to other members? _________

May ANN, Inc. give your name and addresses to medical researchers? _________

ANN, Inc. Caveat: Though discussions on specific problems are permissible and expected, remember that no posting here shall constitute professional health care or medical advice, and you should never rely on any contribution to this, or any, Internet discussion forum on important medical or professional health care questions. Indeed, no Internet discussion forum is a substitute for the careful advice and treatment of a competent professional health care provider or doctor.

ANN, Inc. is a volunteer, nonprofit organization for persons and families involved with nystagmus. ANN, Inc. does not diagnose or treat, or provide professional counseling. It is involved in self-help, while trying to promote research and education, among other goals contained in its mission statement.