Membership Application United Ostomy Support Group, Ottawa, Inc.  (New & Renew) Membership is open to all ostomates, family members, medical and health care professionals, ostomy equipment suppliers and any other interested persons. Name:      ____________________________________________________________ Address:  ____________________________________________________________ City:         ________________________ Prov.: ___________ P.C. :_______________ Phone #: (____)_____________   Email: _________________________ Would you like to receive your newsletter or invoices by Email ___YES___NO   CHECK ALL THAT APPLY:      O  New member            O Renewing member                      O Colostomy               O Urinary Diversion      O Continent Urostomy                      O Ileoanal Pouch        O Ileostomy                  O Continent Ileostomy                      O Female      O Male      O MD, ET, Supplier, Spouse, Etc. How did you learn about UOSGOI?______________________________________________ __________________________________________________________________________ □  NATIONAL MEMBERSHIP: $40 Includes 1 year membership in the Ottawa Support Group, a monthly                    newsletter, membership in UOAC and 2 issues of the Ostomy Canada Magazine (Spring and Fall) □  CHAPTER MEMBERSHIP: $20 Includes 1 year membership in the Ottawa Support Group and a monthly newsletter □   I am unable to pay at this time, but would like to be a member                Yearly Membership Dues:  $_____________                    Donation for the Chapter: $_____________ Donation for the Outreach Program:  $_____________                                                         Total $______________ Make cheque payable and mail to: United Ostomy Support Group, Ottawa, Inc.,                                                            P.O. Box 11134, Station H, Nepean, ON K2H 7T8 Tax receipts will be issued.