National PKU Alliance

Join NPKUA Membership Submission Form

The NPKUA’s mission is to improve the lives of individuals and families associated with PKU through research, support, education and advocacy, while ultimately seeking a cure.

Member Information

*	First Name:
*	Last Name:
	Company:
*	Address:
	Address2:
*	City:
*	State:
	Province:
*	Zip:
*	Phone:
	Cell Phone:
*	Email:

*required information

Membership Levels and Benefits

$25	Individual & Family Membership
	Annual Individual and Family Membership fee is recommended at $25 while encouraging higher donations. Additional donations will be used to support education, advocacy, and communications programs. Benefits include: All communications of the NPKUA, including information on legislative issues and advocacy alerts Discount at NPKUA national conferences Networking capabilities with other members through the NPKUA website Access to the NPKUA Member Discount Program to save money of low protein food orders from Applied Nutrition, Cambrooke Foods, PKU Perspectives and Vitaflo.
$50	Professional Membership
	Annual Professional Membership fee is recommended at $50 for clinics and research institutions while encouraging higher donations. Additional donations will be used to support a clinic survey. Benefits include: Discount at NPKUA national conferences Access to worldwide patient focused news and research Rotating position on the NPKUA Board
$250	Corporate Membership
	Annual Corporate Membership fee is recommended at $250 while encouraging higher donations. Additional donations will be used to support access through the NPKUA to a national database of those effected by PKU. Benefits include: Use of the words “Member of the National PKU Alliance” with the NPKUA logo Cross linking of websites Sponsorship opportunities at NPKUA activities and conferences Rotating membership on the NPKUA board Newsletter and conference materials advertising opportunities

Additional Donations

Amount of Donation: $

My employer will match my NPKUA donation.
The amount of donation: $
Company Name:

I Want to Help the NPKUA!

I am a:

	Parent of a child diagnosed with PKU Child’s Name Birth Year
	Adult diagnosed with PKU Birth Year:
	Relative Name of Related Family Member: * Note, Grand Power is an affiliate organization of the NPKUA encouraging grandparent participation in PKU activities and Please have your grandparents visit: www.GrandPowerNPKUA.org
	Friend Name of Friend:
	Medical or Educational Professional Name of Hospital, Organization, Business, School:
	I give permission for my name, phone & e-mail address to be shared with other individuals and families living with PKU in the same geographical area. Your information will not be shared with any corporations or pharmaceutical companies.
	I want to help raise funds to support the NPKUA.
	I have professional experience in a particular field that might be an interesting lecture topic to present at a future conference. Please explain
I would like to join the following committees:
	Membership/Fundraising Scientific Advisory Advocacy Public Relations PKU Adult Programs