Bayonne Ostomy Alliance Membership Application

Instructions: Print this form, fill it out, and mail it to:

Bayonne Ostomy Alliance
Attn: Larry Pilarski
125 W. 19th Street
Bayonne, NJ 07002-1637

 

Name_________________________________________________________________________

Type of Ostomy________________________________ Date of Surgery__________________

Address: Street_________________________________________________________________

City________________________________________ State _______ Zip _________________

Phone____________________ Email Address ________________________________________

Date of Birth _________________Name of Spouse___________________________________

Name of Doctor/Surgeon__________________________________________________________

  Please check one: I do ( )
I do NOT ( )
give permission for my name to be included
in the Bayonne Ostomy Alliance newsletter
or Membership Directory
 

 


Signature_____________________________________________________________

 

Date application received:________________

 

MEMBERSHIP BENEFITS INCLUDE:

**Treatment & Facilities Guide for Patients and Their Families**

*Monthly support / informational meetings*

**Monthly Ostomy Visitor Newsletter**

*Hot Line Anytime 'Phone Number*

**Social events**

WELCOME ABOARD!


Copyright © 2010 - 2014 Bayonne Ostomy Alliance