REBORN FROM THE ASHES OF DISEASE   - Affiliated with the United Ostomy Associations of America, Inc.

New Membership Application

• Please fill out this application for membership in the Ostomy Association of the Houston Area. Annual dues are $25.00

• Benefits include: The monthly Ostomy Association of the Houston Area Newsletter, participation in local, regional and national meetings, youth rallies, latest information on ostomy management, fellowship and opportunities to help others.

  Attention Treasurer

  Ostomy Association of the Houston Area

  PO Box 25164

  Houston, TX 77265-5164

  ($25.00 Annual dues should be sent to the above address.)

  Name:       

  Email:        (Optional)

  Address1:   

  Address2:   

  City, State & Zip:

  Telephone:

  Date of Surgery:    --  Birth Date:   

  Reason for surgery: Crohn's      Ulcerative Colitis        Cancer

                              Birth Defects       Other               

  Surgery Type
  Colostomy	Continent Ileostomy
  Ileostomy	Continent Urostomy
  Urinary Diversion	Pull-Through
  Other:

  Relationship to patient: Self      Parent of patient         Nurse

                              Spouse/Family member       Physician

   

  Meeting Preference: Central Group:        

                              Northwest Group:    

                              J-Pouch Group:        

                              Baytown:                

  I would like to become a member but cannot pay dues at this time:    (This will be kept confidential).

  I learned about the Houston support group from (OK to select more than one):

       Local UOA Website

       ET Nurse

       Physician

       Newsletter

       Surgical Shop

       Other: 

  Any comments/questions?

  I am enclosing an additional $ as a donation to support UOAA's mission of helping ostomates.

                

  Membership benefits include: Monthly support / information meetings, social events and the monthly Ostomy Association of the Houston Area newsletter.

  We are a health support group, a non-profit, tax-exempt, organization of volunteers whose purpose is to provide mutual aid and education to persons who have ostomies and to their families.  Membership fees and donations are tax deductible.

   

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