Anne Arundel County Ostomy Assocation

Membership Application Please Print

Applicant Information
Full Name:
Last First M.I.

Address:
Street Address Apartment/Unit #

City

State

ZIP Code

Phone:

Date of birth:

Gender:

E-mail Address: Spouse/Support Person

Name Relationship Phone Number

Reason for surgery:

___Crohns

___Ulcerative Colitis

___Cancer

___Other_____________________

To help us complete our records, please answer the following. What type of surgery have you had? Colostomy Ileostomy Urostomy Parent of child with ostomy Spouse/Family Member Other (please specify)

I would like to help with the following committee(s) or activities: Finance Membership Program Sunshine How did you hear about us? Internet Search Hospital ET Nurse Physician Other: Hospitality Newsletter Refreshments Visiting Visiting

The Anne Arundel County, Maryland, Ostomy Association, Inc. (AACOA) is a volunteer-based association dedicated to providing education, information, support, and advocacy to people who have had or will have intestinal or urinary diversions. Members receive The Rambling Rosebud newsletter monthly Please complete the form and send along with your check in the amount of $15.00 payable to: AACOA c/o Stan Baker P.O. Box 847 Gambrills, MD 21054-0847 Membership benefits include: Monthly meetings Monthly newsletter Support information Social events