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RALEIGH AREA CHAPTER UNITED OSTOMY ASSOCIATION
| Name: | Date: | |||
| Telephone: | E-Mail: | |||
| Mailing Address: |
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| City, State, Zip: | ||||
| Year of Surgery: | Spouse's Name: | |||
| Type of Surgery: (Check all that apply) |
[] Colostomy | [] Ileostomy | [] Urostomy (Ileal Conduit) | |
| [] Other: | ||||
| [] I am not an ostomate but would like to be a member. | ||||
| [] I cannot afford the dues but would like to be a member. (Confidential) | ||||
We welcome the membership of ostomates
and other persons interested in the United Ostomy Association and its
activities and appreciate the help they can provide as members. To join,
print the form (in landscape mode), complete and send it with a check or money order for
$20.00 made payable to Raleigh Area UOA
to:
Mrs. Ruth Rhodes
6616 Rest Haven Drive
Raleigh, NC 27612
Dues cover membership in both the local chapter and the national
organization, including subscriptions to the national Ostomy
Quarterly and the local By-Pass.
