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Membership Application Form (for Americans only)

(Our insurance policy is limiting membership to US Citizens)


American Synesthesia Association, Inc.
90 Morningside Drive, 3B
New York, NY 10027


Please fill out the following:

First Name: ___________________________________
Last Name: ___________________________________
Street Address: ___________________________________
City, State, Zip: ___________________________________
Telephone Number: ___________________________________
Fax Number: ___________________________________
E-mail Address: ___________________________________
Website: ___________________________________

Please select from one of the following categories of ASA membership:

Voting Members:
___ GENERAL (must be at least 18 years of age) $50 annual dues
___ SUSTAINING (must be at least 18 years of age) $500 annual dues
___ PATRON (must be at least 18 years of age) $1,000 annual dues
___ LIFETIME (must be at least 18 years of age) $5,000 one time only

The ASA is a not-for-profit, tax exempt organization whose educational mission encourages people to learn more about synesthesia. It is membership supported, so by becoming a member you will actively support this work. We encourage you to join the ASA, and we hope you can attend our upcoming national conference.


Method of payment:

Membership is ONLY for U.S. Citizens over 18 years of age:


Via Credit Card:


Annual Membership
Member Name
Member Email
Note: You do not need to pay via a Paypal account; simply click Pay with Debit or Credit Card.


Via Check or Money Order:

Please print out a copy of this membership, fill it out, and send it with your check or money order via regular mail to:

American Synesthesia Association, Inc.
90 Morningside Drive, 3B
New York, NY 10027



Please make your check or money order payable to the American Synesthesia Association, Inc.