CUB Membership Application

Concerned United Birthparents
PO Box 503475
San Diego, CA 92150-3475

Download a printable version of this form (PDF)

Member's Information

Name:

Street 1:

Street 2:

City: State/Prov.: Zip:

Country: CUB ID #:

Home Tel.:

Email:

Membership Type

Cost

Select

NEW MEMBER, Includes a one year subscription to the CUB Communicator newsletter. Dues same new and renewal.

$40

RENEWAL, please include your CUB ID # in address section above.

$40

How do you want to receive mailings? Choose options below

Electronic Document Delivery: Newsletters and other communications will be sent by email or accessible through our web site. Valid email address required.
	If unable to send email, documents sent by U.S. Mail, should be enclosed in a private envelope.

U.S. Mail Delivery: Mail newsletters to me by U.S. Mail. Other communications will utilize email where possible. Additional U.S. Mail options:

International Postage, required for addresses outside the USA.

$15

Private envelope, add

$15

Donation to help CUB

Total Due CUB

MasterCard or VISA number:

Expires (mm/yy): Name on Card:

Authorized by:

Signature if Mailing:

ADOPTION STATUS: Check all that apply

Birthparent Adoptee Adoptive Parent Spouse/Family Member
Open adoption Adoption Professional

Other - Please Specify:

CUB Branch: Check one if applicable:

Boston, MA Denver, CO Los Angles, CA Louisville, KY
San Diego, CA Twin Cities, MN Washington, DC Metro

To join or renew use one of the following methods:

Print form and mail with check made out to:

CUB, Inc., PO Box 503475, San Diego, CA 92150-3475

Submit form via email with credit card information. (Non-secure site.)
FAX with credit card information to (858) 712-3317
Submit form via email and send check via mail to CUB's address above.
Info email us at: membership@cubirthparents.org

To SUBMIT press Send Form button below