First Name _______________________________________________________________________________
Last Name _______________________________________________________________________________

Address___________________________________________________________________________________
City __________________________________________________________ State _________ Zip__________

Best Phone Number to Contact You _______________________________________________________

Email Address_____________________________________________________________________________

Areas of Interest:
□ Colostomy
□ Ileostomy
□ Urostomy (urinary diversion)
□ Other  (please specify) __________________________________________________________________________________

□ Please check if you are a:
□ family member     □ caregiver      □ medical provider     □ friend

Newsletters are distributed by email. If you do not have an email address and would like the newsletter by U.S. Postal Service, please advise and confirm we have the correct mailing address. Please notify us of a change in mailing address.

Membership applications may be submitted at any meeting or mailed to:

• Capital Regional Ostomy Association
  C/O Phyllis Gibbons
  Membership Coordinator
  12 Adsit Lane
  Clifton Park, NY 12065

Please call Phyllis if you have any questions: 518-371-8368

Annual Membership is $10 and due the first of each January.

Please check here if you would like to be a member but are unable to pay at this time.  □

The purpose of our group is to help people with ostomies to lead full and productive lives, as well as to provide information and emotional support to their families. The members possess collectively, a wealth of knowledge and experience in coping with their ostomies. The information, views, and opinions provided by the group is not intended to be, nor should they be construed as medical advice. Please seek the advice of appropriate medical personnel with regards to any medical condition or treatment.