A CDF Connection Group

Membership Form

Name_________________________________________________________Date_____________________

(Parents' name(s) if celiac is a child) _______________________________Age of the celiac(s) ________

Street____________________________________________________________________________________

City_____________________________________State_________Zip Code_______________

Phone___________________________________ e-mail address_______________________________________

Would you like to have the above information printed in our membership directory?_____

(If you wish to not have any of the above information printed, please specify.) _____________________________________

How were you diagnosed? (Blood tests, biopsy, self-diagnosis) _________________________________________

When? (Year and month)__________________________Do you have Dermatitis Herpetiformis?________

Any other related autoimmune disorders? __________________________________________________________

Could you recommend the doctor who diagnosed you as being someone who is knowledgeable about Celiac Disease?_______

If so, please give his/her name and address.__________________________________________

How did you hear about CSGP?_______________________________________________________________

Have you already joined our parent organization, Celiac Disease Foundation?_______

If so, when did you last renew your membership? (month and year)___________

As a support group of volunteers, we're always glad to have others help out. Please check off any of the following areas in which you might like to help:

Help with set-up or clean-up for meetings______Bring food to meeting _______ Help plan social events _______ Mentor new celiacs _____ Serve on a short-term committee ______

The work Celiac Support of Greater Phoenix does is funded in two ways: 1) annual membership dues, 2) donations. Remember, you can choose to join both CDF & CSGP together or your local CSGP group alone. In either case, you can make your check out to Celiac Disease Foundation and receive a tax deduction. Upon joining, members receive copies of the guidelines that govern CSGP; however, they are also available to prospective members upon request. Thank you.

Please mail this form with your check to Diane Lake, 4142 W. Electra Lane, Glendale, AZ 85310