CHAPTER APPLICATION

PRINT & MAIL

Membership in the Phoenix Ostomy Chapter, Inc. provides you with The Phoenix, our chapter newsletter. Please print out the application and mail with your check and a self addressed stamped envelope for the return of the membership card or you can pick up the card from the Membership Chairperson at one of our meetings. Newsletters are mailed to members and contributors monthly. Inquirers receive 3 complimentary copies, after which we encourage you to join and become a member or make a donation.

HOMEPAGE-PHOENIX OSTOMY CHAPTER

PHOENIX OSTOMY CHAPTER MEMBERSHIP APPLICATON

NAME___________________________________________________

ADDRESS________________________________________________

CITY________________STATE___________zip__________

PHONE_____________________BIRTHDATE____________

I have a ___Colostomy___Ileostomy___Urostomy___Continent Ostomy___Other

Reason for surgery_________________________________________________

Date of surgery_____________________Hospital________________

Amount Enclosed_______

Membership $10.00

Please make checks payable to:

PHOENIX OSTOMY CHAPTER, INC.