MEMBERSHIP APPLICATION FORM

Please fill out and print this Membership Application Form.
Inform us if there is a change in your address.

Name:
Address:
City: State:
Zip: Country:
Phone:
Date of Birth:

Please Check

Ostomy Type:

Colostomy

Urostomy

Continent

Temporary

Ileostomy

Non Ostomy

Check One:Phila Group Abington Satellite Group

I would like to be an ostomy visitor.

Change of Address
Mail with your check or money order made payable to:
Philadelphia Ostomy Association
and mail to:
 POST
P.O. Box 14343
Philadelphia, PA  19115

Effective 1/1/2005, Dues are $15/year which includes membership in the Philadelphia Ostomy Association along with a subscription to the monthly journal newsletter.

Our by-laws provide that persons unable to pay dues, who so notify the membership committee will be considered for a free membership.

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