YOUNG OSTOMATES UNITED (YOU) Inc.

MEMBERSHIP FORM

STATEMENT OF CONFIDENTIALITY

Please complete this form and mail it with your cheque or money order made payable to “Young Ostomates United Inc” to the address listed below.

PLEASE USE BLOCK LETTERS

Mr  -  Mrs  -  Ms  -  Miss  -  Master - Dr    (please circle)

First Name:                                                                  

Surname:                                                                      

Other Names:                                                                             Renewing members – please

Address                                                                                     advise us of any change of

                                                        Post Code                                  address/contact details.

Telephone                                                             Work

                                                                                            Home

Date of birth                                                                

E-mail address                                                                         

REASON FOR SURGERY:  (please tick as appropriate)

Ulcerative Colitis:  []         Crohn’s Disease:  []         Familial Polyposis:   []

Congenital:  []           Spina Bifida:  []           Cancer:  []           Trauma:  []

Other (please state):                                                    

Year of stoma:    [][][][]

Type of stoma/s                                          Annual           Please

(please tick as appropriate)                      Membership      Complete

Colostomy                     []

Ileostomy                     []                            $15.00             $

Urostomy                      []

J-Pouch                        []

Pensioner

(Pension No.:                                 )          $10.00             $

Professional Consultant                          $15.00             $

Interested person                                  $15.00             $

Donation                                                $                      $                 

                                                             TOTAL:        $                 

Where did you hear about YOU Inc?                               

                                                                                                         

 

Membership Period 1^st March to 28^th (29^th) February annually.

Please enrol me as a member and send meeting details.

 

Telephone Directory Authority

I am willing to have my name and telephone number/e-mail address circulated solely to other members of YOU Inc to offer moral support.

Yes:   []                          No:   []

Signed                                                                         

Dated                                                                           

 

YOUNG OSTOMATES UNITED Inc

P O BOX 1433 MDC

NARRE WARREN  VIC  3805  AUSTRALIA