Information on Prospective Member

First Name* required

Middle Initial

Last Name

City
Select a CityBrooklynBronxManhattan

Address 1

Address 2

Zip Code

Daytime Phone Number

Evening Phone Number

Cell Phone Number

Email Address* required

Information on Referral Source

Name of Person Making the Referral* required

Relationship to Person Referred

Title (if applicable)

Referring Agency (if applicable)

Address 1

Address 2

City

State

Zip Code

Phone Number

Cell Phone Number

Email Address* required

Website (if applicable)

How did you find out about ICS?
Friend/Relative/Colleague Physician/nurse/other health or social service provider WebTV/Newspaper/Magazine Other

Would you like to receive email notice of ICS events such as health education workshops, wheelchair tune-up classes, art exhibits, and more?
YESNO

Would you like to receive our e-newsletter ICS News & Notes?
YESNO

Shall we make our initial contact with the person you are referring, or with you?
Contact meContact the person I am referring

That’s all we need for now. You may print out this form and fax it to our dedicated Referral Fax line at 718-907-1682, or click here to