Education and support for those dealing with hypospadias and epispadias

Thank you for your decision to become a member of HEA. 

If you prefer to pay by mail rather than online, please fill out the following information and press the SUBMIT button to notify us of your pledge.  Then mail your check to:

HEA Treasurer

P.O. Box 475
Wauconda, IL 60084


Your information will NEVER be shared with any
other organizations, companies, or individuals!

(Items in red are required):





Your Name:

Affiliation:


(optional:  you may enter other family members living at the same address)

Spouse/Partner:

Affiliation:





Other Adult:

Affiliation:





Child #1:

Affiliation:

 

Birthdate:





Child #2:

Affiliation:

 

Birthdate:





Child #3:

Affiliation:

 

Birthdate:









Your e-mail address:




Address 1:

 

Address 2:

 

City:

 

State/Province:

ZIP/Postal:

Country:

Telephone:





Do you want to be included in the HEA mailing list?

Yes  No

By selecting "no", you will not receive occasional updates from HEA, but you will continue to receive messages directly related to your membership.





Do you want us to add you to our online member database? (first name, e-mail address, city and state only) Yes  No




Membership category

(select one)   





Donation Amount

(Benefactor or President's Circle only)

$ USD



Comments: