Please fill out this form and mail it with an enclosed check to the Center at the following address:

Illinois/Iowa Center for Independant Living
P.O. Box 6156
Rock Island, IL 61204-6156

 

Name:
Address Line 1:
Address Line 2:
City:
State: Zip:
Phone or TTY: () -
 

 

I would like to enroll as (please circle one):

$10 Individual $35 Organization $100+ Century Club $250+ Mentor's Club
$25+ Contributor $60 Business $150+ Patron's Club $500+ Benefactor

 

____ Please call me to discuss other ways in which I can help the IICIL.