Reborn from the Ashes of Disease

Membership Application

Greater Cincinnati Ostomy Association

To join, please fill out this form, or contact us by telephone or e-mail. There is no charge to join the Greater Cincinnati Ostomy Association, but if you are able, we ask that you send a tax deductible donation to help cover our expenses. We still require that you renew your membership each year, and ask that you consider sending in a donation to help us provide our newsletter service. Suggested tax deductible donation is $20.00, although we would greatly appreciate, if you are fortunate enough, to round it up to $25, $35, or even more. You can fill out this form, print it and mail it to us with a check, or you can fill out the form and hit the Submit button to send it electronically. Thank You!

All information on this form will be kept confidential.

Name

Address

City State Zip Code

Home Phone Work Phone

E-Mail

Type of Surgery Other

Method of registration:

Please contact me to schedule an Trained Ostomy Visitor:

If you are not submitting the membership application electronically, please print out this form and mail it with your donation to:

Greater Cincinnati Ostomy Association
7942 Schoolhouse Lane Cincinnati, Ohio 45242

If you have any questions or comments, please contact us at:
Voice Mail: (513) 202-3345 or