Online Membership Form

By mid-July, you will be able to join completely online! Until then, you may submit your membership form electronically by completing the form below, then, after submitting the form, sending a check made out to NCCNA to PO Box 6985, Auburn, CA 95604. You may also download and complete the form by hand to send with your check.

NCCNA Online Membership Form

*First Name:
*Last Name:
*Address:

*City:
*State:
*Zip:
*Primary Phone Number:		This is a
Alternate Phone Number:		This is a
E-mail Address:
Occupation:
	(If retired, please also list your previous occupation)

Please indicate:	New Membership Renewal
Select your support group:
Send Newsletter:	By E-Mail Through Standard Mail

Please provide the following information so we may serve you better
(NOTE: This information is used only to help us provide useful information and address member concerns. No
information is shared with third parties, except some aggregate data used for grant applications or research)

Are you diabetic?	Yes No

What are your primary symptoms? Check all that affect you frequently:
Difficulties walking or standing		Weakness in limbs	Burning
Sensitivity to touch or pressure		Coordination problems	Cold
Sensation of stocking or glove		Sharp, stabbing pain	Numbness
Other		Electrical sensations	Tingling
Not personally afflicted		General pain	Pins & Needles

	What caused your neuropathy?

How did you hear about the NCCNA?

What do you hope to receive by being involved with the NCCNA? Check all that apply:
Understanding of my situation		Information	Support
Provide aid to group or others		Treatment ideas	Friendship
Other		Coping strategies	Sympathy
Not personally afflicted

Additional Comments:

			*Required field