RESOLVE of the Bay State - Membership Application



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Peer Discussion Groups

Topic Discussion Groups

Upcoming Programs:

Elective Single Embryo Transfer (eSET)
Tuesday,
July 27, 2010
6:30 - 8:30 p.m.

Getting the Most from
Your Infertility Insurance Coverage
Wednesday,
September 22, 2010
7:00 - 9:00 p.m.

Membership Application

Household Membership: $55 per year
Professional Membership: $150 per year

(This is a printable form. Please fill in the required information, and then print and mail, or fax with your credit card information. Or, become a member now online) Mail to: RESOLVE of the Bay State, 395 Totten Pond Rd., Suite 403, Waltham, MA 02451. Fax to 781-890-2249.)

Name:

Address:

City:

State:

Zip:

Phone:

E-mail:

Please choose membership type:

Household - $55 per year

Professional - $150 per year

My check is enclosed

Or charge to my:

Visa

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Card #

Exp.Date:

Signature:
______________________________

I would like to order the following information packets:

Adoption Information - $10

Donor Egg Information - $20

Insurance Information - $5

I would like to help further the work of RESOLVE of the Bay State by enclosing an additional tax-deductible contribution:

Contribution - $

I would like to receive weekly email updates with program and event information:

Yes

I am interested in information on (please select all that apply):

Primary Infertility

Secondary Infertility

Male Factor

Pregnancy Loss

Donor Egg

Adoption

Other: (please specify)

If you would like to receive weekly email updates with
program and event information, please send us an email
with the word "Subscribe" in the subject line OR type your email address
in the "Join Our Email List" box and click on "Join."

395 Totten Pond Rd, Suite 403
Waltham, MA 02451

HelpLine: 781-890-2225
Fax: 781-890-2249
email: admin@resolveofthebaystate.org
website: www.resolveofthebaystate.org

Important Note: The information contained in this site is not intended to be a substitute for professional medical advice. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition. Nothing contained in this site is intended to be a substitute for medical diagnosis or treatment.