Share This Page!

United Spinal Iowa Membership Form

Individual membership is free and open to people with spinal cord injuries or disorders, family members, care providers and professionals, and interested individuals.

Age Restrictions
You must be 18 years or older to qualify for membership in United Spinal. Parents and guardians of children under 18 years of age are encouraged to become members by completing the application. Please enter your information and not information pertaining to your child.

In addition to the Iowa chapter, feel free to sign up for the National United Spinal membership here: United Spinal Membership

Contact Information

Title
MissMsMrsMrDr

First Name (required)

Last Name (required)

Email (required)

Street Address (required)

City (required)

State (required)

County (required)

Zip (required)

Telephone#

About You

Year of Birth (required)

I am 18 years of age or older (required)
Yes

Gender (required)
MaleFemale

Are you a U.S. Military Veteran (required)
YesNo

About Your Disability

Your Disability (required)
Spinal Cord InjuryAmyotrophic Lateral SclerosisPolioAmputeeCerebral PalsyMultiple SclerosisSpina BifidaStrokeMuscular DystrophyTraumatic Brain InjuryNoneOther

Year of injury

Level of Function (required)
ParaplegicQuadriplegicHemiplegicDifficulty GraspingDifficulty WalkingVentilator DependentNot ApplicableOther

Are you a wheelchair user (required)
NoManual WheelchairPowered WheelchairMobility ScooterSports WheelchairStanding WheelchairOther

Inpatient Rehabilitation (required)
YesNoNot Applicable

Other

I would like to be contacted (required)
YesNo

Would you like Spinal Cord Injury Peer Support Group information
YesNo

How did you find out about United Spinal Iowa (required)

If other is selected