Join

Deaf Seniors of
Georgia
Membership Form

Date: _______________
Please Print Clearly!
Name: ____________________________________________________________
Date Of Birth: _____________________________________________________
Single/Married/Widow(er)
Spouse Name: (if he/she is included for membership)
__________________________________________________________________
Spouse Date Of Birth:_______________________________________________
Wedding Anniversary: ______________________________________________
Address: __________________________________________________________
City/State/Zip: _____________________________________________________
VP: ______________________________________________________________
E-Mail:___________________________________________________________
Do you prefer to receive DSG Newsletter through email or mail?___________
$15.00 / Person / Year
Make check payable to DSG (NOT to Debra Barnick)
Send check and Membership form to:
Membership Chair
Debra Barnick
9515 Kraft Dr
Winston, GA 30187

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