Houston Celiac Support Group

www.houstonceliacs.org

MEMBERSHIP FORM 2018

 

Renewal (or only newsletters) - $20  {       }       New Full Membership -$25 {       }                                       

 

Name  ­­­­­­­­­­­­­­­­­­­­­­­­­________________________________________________________________                                                                                                                            

Address  ______________________________________________________________

City                                      State                        Zip _________________________                                  

Phone, home _____________________          Phone, work: ____________________                                   

*E-mail address, please confirm:   ________________________________________ 

 

*We need to confirm your current address. Also, we intend to e-mail newsletters now in order to save money. If you want a hard copy, please let us know below.

(1) OK to send newsletter via e-mail: YES (   ); or


(2) Please send a hard copy to my address above: YES (   )

*Gastroenterologist (Houston area) (please confirm) ________________________                                              

 

ENCLOSED IS MY FULL MEMBERSHIP CHECK FOR $25 or RENEWAL MEMBERSHIP CHECK FOR $20, payable to Houston Celiac Support Group.

Please mail check to: (Treasurer) Andrea Maher, 2411 Chatham Creek Court, Houston, TX  77077,  phone: 281-493-3185.

 

Donations are always welcome and very much appreciated. Your donation is tax deductible because CSA/USA is a non-profit {501- 3(C)}organization. Thanks again.

 

The  member/patient is:  (   )  baby,   (   )  child,    (   )  teenager --

       Date of Birth of child:                                       ;    (    )   adult;   (    )  has DH.

 

How was patient diagnosed:  (    )  Biopsy;   (     ) Antibody Blood Tests;

          (    ) Elimination diet,  (     ) Self-diagnosed(   )  Other {please explain}:                                                                                                                  

 

Other food intolerances or conditions: ________________________________   

                                                       ___________________________________________

 

GF DINING CLUB:  Interested in being notified about new Dining Club events:

            (  )  Yes.  (Usually for adult members and their guests)

 

SUGGESTIONS FOR PROGRAMS _________________________________________________________________________

Thank you for your renewal or new membership!   We hope we are and have been responsive to your needs. We appreciate your suggestions and ideas for programs.                                      Thanks, Janet (281-679-7608)