Membership Form

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Triangle Area Ostomy Association

		Date:
Name:		Spouse:
Mailing Address:
City, State, Zip:
Home Telephone:		Cell Phone:
E-Mail address:
I would prefer to receive the newsletter via:		[ ] E-mail.	[ ] US mail.
Date of Surgery:	[ ] Year:
Type of Ostomy: (Check all that apply)	[ ] Colostomy	[ ] Ileostomy	[ ] Urostomy (Ileal Conduit)
	[ ] Other:
I am not an ostomate but would like to be a member	[ ] TAOA Supporter	[ ] Relative	[ ] Friend
	[ ] Other
Comments:
[ ] Active Membership: Member for UOAA/TAOA. Annual Dues $20.00.
[ ] Courtesy Membership: Cannot afford dues at this time. (Confidential).
[ ] Affiliate Membership. WOCN’s & Prof . Associates. Dues exempted.
IMPORTANT: ALL CHECKS MUST BE PAYABLE TO TAOA.
ENCLOSED: $________________________	[ ] Cash	[ ] Check	[ ] Money Order
[ ]Donation (optional)		$______________ For our support of FOW.
[ ] I wish to have a Courtesy Membership without Dues at this time. (Confidential)

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We welcome the membership of ostomates and other persons interested in the United Ostomy Association of America and its activities and appreciate the help they can provide as members. To join, print the form (in landscape mode), complete and send it with a check or money order for $20.00 made payable to Triangle Area Ostomy Association to:

Mrs. Ruth Rhodes
8703 Cypress Club Dr.
Raleigh, NC 27615

Dues cover membership in both the local chapter and the national organization, including a subscription to our local newsletter, By-Pass.

If you would prefer, you may click here to download a copy of the membership form in Word .docx format to print offline.