Houston Celiac Support Group
MEMBERSHIP FORM 2022-2023
►National Celiac Association Info at the BOTTOM
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 NO ( )
(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)
►National Celiac Association
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)
Updated 22Oct22