Membership Process - Individual Membership

Join IWRC - Individual
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Every field with an asterisk (*) should be completed. Where available, you may hover your mouse over the icon for help

General Information

*First Name:

*Last Name:

*Address1:

Address2

*City:

*Prov/State:

*Country:

*Postal/Zip:

*E-mail:

*Please confirm email:

Phone:

2nd Phone:

Joining or Renewing?

Joining Renewing

Complete the following only if you normally use them with your name.

Prefix Title:
(Dr.)

Middle Initial:

Suffix Title:
(PhD, DVM)

Rehabilitation and Online Directory Information

The following information is included in the Online Directory. For a list of fields that will be displayed in the Online Directory, click here.

Include you in
Online Directory?

Yes No

E-mail notification?

Yes No

Affiliation:

Specialties:

Avian	Mammal	Other

Statistical Information

The following information will only be seen by IWRC staff. IWRC represents its members to many organizations in order to promote wildlife rehabilitation. The following information will help us compile statistical data about our members and the rehabilitation community. Only complete it if you feel comfortable doing so.

Are you active in rehabilitation or a related field?

Yes No

If Yes, how many years have you worked in rehabilitation?

Do you work alone or with a group?

Alone Group

Do you work under a permit?

My own permit
Group permit
No permit

What kind of permit

Prov/State
Federal
Both

Do you work under other permits?(Hold down Ctrl key to select more than one)

How many animals have you rehabilitated in the past year?

Which rehabilitation organizations do you belong to? (Press Ctrl to select more than one)

Other

Which environmental organizations do you belong to? (Press Ctrl to select more than one?

Other

Educational Background

Describe any additional rehabilitation-related training you may have

Would you be interested in being a committee member? If so, select one

What qualifications do you have that you feel would be beneficial to IWRC?

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If you prefer to mail or fax in your membership, please print this page, include your payment, and send to: IWRC PO Box 8187 San Jose, CA 95155 Fax: (408) 271-9285 Questions? Call us at (408) 271-2685