London & District Ostomy Association P.O. Box 24206 • London, ON • N6H 5C4 Membership Form | Annual membership fee is $30.00 and includes: monthly meetings, bi-monthly newsletters, and subscription to Ostomy Canada magazine. |
The information you provide will be kept strictly confidential and never released without your consent. [ ] Change of Address Only [ ] New Membership • [ ] Renewal |
| Name | ______________________________________ |
| Address | ______________________________________ |
| City | ________________ Postal Code __________ |
| Phone | ______________________________________ |
| Fax | ______________________________________ |
| ______________________________________ | |
| [ ] Ileostomy [ ] Colostomy [ ] Urostomy [ ] N/A [ ] Other _____________________________________ |
| For new members • How did you learn about LDOA? [ ] LDOA Web Site [ ] UOAC Web Site [ ] Physician or ET [ ] Family or Friend [ ] Other _____________________________________ | |
| Comments | ______________________________________ |
| _______________________________________________ | |
| _______________________________________________ | |
| _______________________________________________ | |
| _______________________________________________ | |
If you are joining LDOA as a new member or renewing your existing membership, don't forget to enclose your cheque made payable to London & District Ostomy Association | |
Thank you for your support. If you are a new member, please introduce yourself at the next meeting. We look forward to getting to know you!
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London & District Ostomy Association is an affiliated Chapter of the United Ostomy Association of Canada. |