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Rapides Parish Ostomy Association

 United Ostomy Association Youth Rally Information Page

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

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