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National Black Disability Coalition Membership Form

This form is for individuals interested in joining the National Black Disability Coalition as either a Member-at-Large or an Affinity Group Member (Youth, Entrepreneurship, Research & Policy, or Health).
Membership is free, and honoraria are provided to members of Affinity Groups.
We welcome Black-disabled individuals, caregivers, and allies from across the Black diaspora — including 2SLGBTQIA+ folks and those with lived experience in disability, health, and systemic barriers.
Please complete this form to express your interest in joining the Coalition and contributing to this growing national movement for Black disability justice.
1.First Name(Required.)
2.Last Name(Required.)
3.Email Address(Required.)
4.Phone Number(Required.)
5.LinkedIn
6.Social Media(Instagram handle)
7.City/Town(Required.)
8.Province
9.Have you participated in Ase capacity events or programming?(Required.)
10.Please list the names of organizations you are involved with and describe your role.(Required.)