Rapides Ostomy Support Group Membership Application

Membership is open to anyone interested in ostomies and continent procedures.

Today's Date __________________

Name ___________________________________Date Of Birth __________

Address ________________________________________________________

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 !!