Disability Caucus
of the United States Green Party
Membership Application

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Please fill out this form to join the Disability Caucus. If you prefer, you can email the information directly to our Membership Committee at dg-mem@immuneweb.org. Please contact the Membership Committee if you have any questions.

There are two kinds of members, voting (verified) and adjunct. Voting members are Green Party members who are disabled. Adjunct members are anyone else interested in the work of the Caucus.

Voting Member:

This information is required by the US Green Party. It will not be made public. The information you give us goes to appropriate Caucus staff and Green Party committees.

Name used with Register of Voters:
Email address used to subscribe to the Disability Caucus mailing list:
Any other email addresses you use to subscribe to the Disability Caucus or related mailing lists and your Yahoo ID, if not obvious from your name or email:
Email address you prefer for contact, if not listed above:
Mailing address (must be in US, otherwise go to Adjunct Member form):
Phone number (optional but helpful):
County Name (optional but helpful):


Please choose one of the following:

I am registered to vote as a Green in my state.

My state does not have a Green Party but I am active in Green organizations.

My state has a Green Party but I am not eligible to register to vote, I am active in Green organizations.

Note: If you do not fit one of these categories, go to Adjunct Member form.


I identify as a person with a disability:

Yes

No

Note: Your answer must be "yes" to be a Voting Member. Non-disabled people are welcome as Adjunct Members.


I agree to follow major discussions and participate in votes.

Yes

No

Note: Your answer must be "yes" to be a Voting Member.

Additional Information (optional)


Disabled Greens Mailing List:

I am already a member of the Disabled Greens or Disabled Greens Votes List(s) or will be very soon.

I need help subscribing, please contact me at

I do not have internet access, please contact me at

Please enter any additional comments here.

   

Adjunct Member:

This information is required by the US Green Party. It will not be made public. The information you give us goes to appropriate Caucus staff and Green Party committees.

Adjunct members are allowed to be on the mailing list(s) and participate in discussions. They may not vote. Other Caucuses do not allow adjunct members at all but the Disability Caucus does allow non-disabled people to join us in furthering disability issues.

Because the Caucus is an official group of a political party, we need to know who is on our lists. You do not need to give much information but some is required.

Name (full legal name preferred but a way to identify you is sufficient):
Email address used to subscribe to the Disability Caucus mailing list:
Any other email addresses you use to subscribe to the Disability Caucus or related mailing lists and your Yahoo ID, if not obvious from your name or email:
Email address you prefer for contact, if not listed above:


I am choosing to be an Adjunct Member because (check all that apply):

I am not disabled.

I am not a Green Party member.

I do not live in the United States.

I can not make a commitment to the Caucus.

Other:

Please enter any additional comments here.

   

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