Rapides Parish Ostomy Association

 United Ostomy Association Youth Rally Information Page

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The Rapides Parish Ostomy Association would like to sponsor one child from this area. To be considered for sponsorship please fill out the below application and mail to:

Rapides Ostomy Association

310 Walker Gravel Pit Road

Dry Prong, LA. 71423

or E-Mail the information to our e-mail address at the bottom of this page. We will send you a formal application and additional details.

For more information regarding the Youth Rally visit the UOA web site.

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 ;)

Date of initial surgery _________ Hospital ______________________

Your Current Physician __________________________________________

Do you mind if your name is mentioned in our newsletter? _____

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© 1998 Rapides Ostomy Association / Rapides Ostomy Association