Membership Application

If you wish to become a member of the Regina Ostomy Chapter, please fill in the form below, print it off and send to the address indicated.

APPLICATION FORM:

Name: _______________________________________

Address: ______________________________________

City/Town: ____________________________________

Postal Code: ___________________________________

Phone: _______________________________________

Email: _______________________________________

Please check all that apply:
( ) Colostomy
( ) Ileostomy
( ) Urostomy
( ) Continent/J pouch
( ) Partner/Family member
( ) Medical professional

Please make cheques payable to: Regina Ostomy Chapter and mail with this form to: 942 Brachman Bay, Regina, SK., S4N 7P2.