Membership is open to anyone interested in ostomies and continent procedures.
Today's Date __________________
Name ___________________________________Date Of Birth __________
City _____________________________ State ______ Zip ____________
Telephone Number ____________________
Check all that apply;
___Colostomy ___Ileostomy ___Urinary Diversion
___Continent Urostomy ___Continent Ileostomy ___Other Supporter
___ Other (please specify)______________________________________
___ I had an operation but am not really sure what you call it ;)
___ Spouse/Friend/Family Member
Date of initial surgery _________ Hospital ______________________
Your Current Physician __________________________________________
Your Occupation ____________________________
Do you mind if your name is mentioned in our newsletter? _____
Are you interested in becoming a trained visitor for other ostomates? ____
Members Dues are $15.00 per Year (no one is turned away for inability to pay).
___ I cannot pay dues now, but please keep me on your membership list.
Make checks payable to: Rapides Ostomy Support Group
Mail application and check to : 310 Walker Gravel Pit Road, Dry Prong, La. 71423
ALL OF US WELCOME YOU IN YOUR DECISION TO BECOME A MEMBER. WELCOME !!
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© 1998 Rapides Ostomy Support Group / Rapides Ostomy Support Group