Courage Kenny Handiham Program Membership Application

Membership connects you with amateur radio operators with disabilities across the world, and with the equipment, training and support the Handiham Program provides.

Fields marked (required) must be completed before you can submit this application.

About Your Membership (required)

Which best describes you?

A new member

A renewing member

An associate member

A student learner

General Information

Applicant name (required)

What is your preferred name? (required)

Address (required)

City, state and ZIP code (required)

Email (required)

Primary phone number (required)

Date of birth (required)

Month, day and year.

Gender (required)

Call sign

Leave blank if you do not have one.

License class

Leave blank if you do not have one.

Racial and Ethnic Background (required)

The Handiham Program receives public funding from sources that request statistical information about the racial diversity of our members. Please select the race you most closely identify with. If you would rather not answer, select "Decline to provide".

White, not of Hispanic origin

Black, not of Hispanic origin

Asian or Pacific Islander

Hispanic

Native American (Indian American, Native Alaskan)

Another background, described below

Decline to provide

If you selected "Another background", please describe it

Health Related Information

We ask for this because the Handiham Program exists to serve people with disabilities, and our grant funding requires us to report on who we serve.

Primary disability (required)

When did you become disabled? (required)

A year, an age, or "from birth" is fine.

Please list the adaptive devices you currently use (required)

For example a screen reader, braille display, key guard, hearing aid or mobility device.

Membership Dues and Payment (required)

Please select your membership.

One year membership — $15.00

Two year membership — $30.00

Three year membership — $45.00

Lifetime membership — $150.00

How would you like to pay? (required)

By check or money order, made payable to Courage Kenny Handiham Program and mailed to: 3915 Golden Valley Road, MR #78446, Golden Valley, MN 55422. Your membership will be activated when payment arrives.

Online by credit card, using our secure payment site.

By credit card, but please call me for the details rather than using the website.

Secure Payment Link

If you are paying online, use our secure payment site: Courage Kenny Handihams — Patient Payment (InstaMed)

Handiham Radio Club

The Handiham Radio Club is open to members of the Handiham Program, and there is no additional cost to join. Joining is entirely optional, and your Program membership is unaffected either way.

Yes, I would also like to join the Handiham Radio Club.

Members Only Website (required)

Members get access to the Handiham members-only website at handiham.org.

Choose a username (required)

Pick something you will remember. We will set up your account and email you a temporary password, which you can change the first time you sign in. Please do not send us a password.

Education (required)

Please tell us a little about your education, including any special field of study.

Communication Hobby Goals (required)

Select all the goals that apply to you.

I want to use voice communication.

I want to use Morse code.

I want to communicate by using a keyboard.

I want to learn more about short-wave radio.

Talking around the world.

Local radio contacts via repeaters using a hand-held radio.

The social fun of talking with others and making friends via radio.

Agreement and Signature (required)

If you are joining as a member with a disability, please type your name below to acknowledge that you agree to the following statement:

I wish to apply for a membership in the Courage Kenny Handiham Program. I agree to abide by Handiham Policies. My membership dues payment will no longer be refundable once my membership has been active for 14 days.

Type your name to acknowledge the statement above (required)

Signature (required)

Type your full name.

Today's date (required)

About the Enter key. To tick a box or choose an option, press the spacebar. If you press Enter anywhere in this form you will be taken to a page listing what you have filled in so far, where you can carry on or send it. Nothing is sent until you choose "Submit application".

After you select Submit, a confirmation page will tell you that your application has been received. That page is your confirmation. We will also try to email you a copy, though if you use a forwarding address such as @arrl.net it may not reach you. If you do not see the confirmation page, please email us so we can make sure your application arrived.

Questions?

Please write to the Courage Kenny Handiham Program at handiham@allina.com.