OAB Please enroll me in the
Ostomy Association of Boston . Fill in this membership form and print.
Send it with your personal check
for membership to cover your
first year's membership dues.
| Price | Type of Membership | Renewal (N/Y) | Check One |
|---|---|---|---|
|
$22.50 |
Active Membership | ||
| $75.00 | Donor Membership | ||
| $100.00 | Patron Membership | ||
| $50.00 | Professional Membership for health professionals | ||
| $60.00 | Corporate Membership | ||
| Complimentary Membership for all area RN ET WOCNurses | |||
| Please make checks payable to : OAB, Inc. |
| Name: |
| Address: |
| City State: zip: |
| Phone: (Home) (Work) |
| Email Address:Date of Birth: |
| To help us complete our records, please answer the following. Check all that apply. | ||
| Colostomy | Ileostomy | Urostomy |
| Continent Ileostomy | Continent Urostomy | Pull-Through |
| Parent of Child with Ostomy | Other Continent Procedure | Medical Product Supplier |
| Spouse / Family member | Medical Professional (Physician, CETN, RN) | |
| Other | ||
| In addition, I would like to give a donation of for the following OAB/UOA programs: | |||
| Visiting | Education | OAB Bulletin | Peer Support |
| Parents of Ostomy Children | Public Awareness to Stop the Stoma Stigma! | ||
| Help a child with an ostomy attend the Youth Rally Summer Camp | |||
| Other (Please specify) | |||
| I would like to volunteer help OAB achieve its mission of support for all those in need of ostomy or continent procedure surgery. I can help with: | ||||
| Computer Skills | Web development | Visiting | Legal affairs | The Bulletin |
| Events Planning | Fund Raising | Public Awareness Campaign | ||
| Other (Please specify) | ||||
| Please print this form and send to: |
| C/O Jerry Werther |
| 1612 Worcester Road Apt. 511 |
| Framingham, MA 01702 |
| All dues and contributions are tax deductible. |