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Membership Application
We invite everyone to join our Chapter. You are especially welcome if you have an ostomy, are
preparing for surgery, are a health care professional, or have a loved one who has had surgery.
We are a completely volunteer ostomy support group.
Name:________________________________________________________________________
Address:______________________________________________________________________
City:______________________________________ State:_____________ Zip______________
Phone:(_________)________________________ e-mail: ______________________________
Your appropriate age group: 10-20 20-40 40-60 60+
Type of surgery: Colostomy Ileostomy Urostomy Continent Procedure
Date of surgery:___________________ Hospital of surgery:____________________________
Attend one of our General Meetings. There are always friendly people to talk with you. You may
even learn about the available opportunities on our Committees. We always have a need for
talented people to share in our good work.
Our membership dues are $10.00 a year.
Please mail this application and a check
payable to the
Birmingham Ostomy Association
for $10.00 to:
Cindy Bloom
5576 Heath Row Drive
Birmingham, AL 35242
For any questions about this form, please contact Lyn Hayes at lynlhayes@aol.com or 205-907-3406.
All well- intentioned people are invited to attend our General Meetings. Admission is free.
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