ICB Membership Form

Please use the following form if you want to become a new ICB Member, renew your membership or become an ICB Life Member. If you are a Life Member who needs to update any information such as Name, Address, Phone Number or Email Address, please Email the ICB Office or call 217-523-4967. If you are a member of one of ICB’s 5 chapters, please ask the Chapter how they want you to go about renewing your membership to minimize any possible confusion.

Membership Type(Required)

New

Renewal

Life

What type of membership (new, renewal, life)

Full Name(Required)

Please Enter Your Name

Address Line 1(Required)

Address Line 2 (Optional)

City(Required)

State(Required)

Zip Code(Required)

Primary Phone(Required)

Alternate Phone (optional)

Email Address(Required)

ICB Affiliates you Are Interested in (Check all that apply)

American Council of the Blind of Metropolitan Chicago

Madison County Association of the Blind

Springfield District Association of the Blind

Mary Bryant Home for the Blind Association

Illinois Braille Revival League

Communication Preferences

Communications from ICB

How would you like to receive materials from ICB

Illinois Braille Messenger

How would you like to receive the Illinois Braille Messenger, ICB’s quarterly publication

ACB Braille Forum

How would you like to receive the ACB Braille Forum?

Demographic information

Gender

Race/Ethnicity

Dues and Donation

Membership Dues(Required)

Based on Membership Type Selected

Additional Donation

Please enter any additional donation you would like to make to ICB

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Pay Pal Fee

Total

Product Name

Price: $0.00

Total

Payment Method