Contact Information:

First Name
Last Name
Middle Initial
Address (cont.)
City
State/Province
Zip/Postal Code
County/NY Region
Work Phone
Home Phone
FAX
E-mail
URL

Emergency Contact Information

About You:

Date of Birth
Sex	Male Female

Select Membership

$108 - Lifetime
$65 Dual/Family
$40 Individual
$15 Student/Senior
 

Please note: Membership is not tax-deductible at this time.

As a condition of your membership, certain benefits require us to release your name, e-mail, and address to our partners. You can read about how your information is used in our privacy policy. Please check this box if you do not wish to have your information released.

Do not release my information to your partners. I understand that checking this box limits the discounts and benefits of my BVSNY membership. I understand that if I decide to participate at a later time in the benefits and discounts offered to BVSNY members, I may be subject to the full terms of the partnering companies and may not be entitled to a discount. Click here to read the privacy policy.

Please list your name as you would like it to appear on your membership card:

I am interested in:

Restaurant Outings
Potlucks                                             
Nutrition Education-Pregnancy	
Nutrition Education-General/Transitions
Nutrition Education-Children 
Nutrition Education-Seniors
Nutrition Education-Athletes
Events                                 
Discounts 
Travel                                   

I am willing to help with (select all that apply):

Development - Board Planning
Development - IRS filing                                      
Development- Membership - Individual/Corporate
Development -Marketing/Outreach 
Development- Brand Identity 
Development - Fundraising/Grantwriting
Development - Corporate/Community Partnerships
Education  
Event Planning   
Special Interest Groups - Pregnancy                              
Special Interest Groups - Elder Vegetarians 
Special Interest Groups - Children                                  
Special Interest Groups - Disease Management     
Special Interest Groups - Spiritual                                 
Special Interest Groups - LGBT  		    
Special Interest Groups - Borough/Regional Clubs
Travel                                           
Writing                                           

I consider myself:

A Vegetarian
A Vegan
In Transition
Veg-Curious/Omnivore

How did you hear about BVSNY:

Friend
E-mail
Myspace
BVSNY website
Internet Search
BlackPlanet
Tribe.net
Friendster
Other:

Clicking 'Submit Form' will take you to the confirmation page, where you will be presented with payment instructions. Your membership will not be processed until your payment is received.

I am mailing a check or money order (make payable to Black Vegetarian Society of NY or BVSNY)