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United Ostomy Associations of America, Inc.Ostomy Support Group of Lawton-Fort Sill (OK) |
Use this form to join our chapter! Annual dues are US$20.00. We're not yet set up to take payments online; therefore, we will bill you if you submit this form electronically. If you prefer, you can print this form and mail it with payment to the address below* without using the "Submit Application" button. If you cannot afford to pay dues at this time, you may still be accepted as a member for a period of 6 months.** You do not have to be an ostomate to be a member and/or support the work of UOAA. THANKS!!!
All information on this form will be kept confidential.
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Online Membership Application Form
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Your Name | |
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Your Street Address | |
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Your City | |
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Your State | |
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Your Zip Code | |
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Your Phone Number (home) | |
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Your Phone Number (work) | |
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Your Date of Birth (mo/da/yr) | |
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Your E-Mail Address | |
| Colostomy | Ileostomy |
| Urostomy | Ileoanal Pull-thru |
| Continent Ileostomy | Continent Urostomy |
| None | Other |
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Any help/information desired, or additional comments: | |
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* If you prefer to print out this form, mail with your dues payment to:
Bob Dishman, Treasurer
Ostomy Support Group of Lawton-Fort Sill (OK) ,
United Ostomy Associations of America, Inc.
735 NW Heinzwood Circle,
Lawton, OK 73505
** Ostomates who cannot pay dues may become a member of the Ostomy Support Group of Lawton-Fort Sill (OK) for a period of 6 months. During this time, you will receive the Ostomy Support Group of Lawton-Fort Sill (OK) newsletter.