|
Gluten Intolerance Group of North Dallas
Membership Form
Today’s Date: mm/dd/yyyy
Name(s) of person(s) joining or renewing (may be one or more family members, one should be an adult):
(Last, First Initial)
Address:
City: State: Zip:
Home Phone: Work: Cell: ex 972-333-3434
E-mail address:
Suggested Username(s) for website:
For new members, when your paperwork is complete, you will be assigned one of your suggested Usernames and a temporary Password . When you login for the first time, you will be prompted to change the Password to something of your choosing.
Check all that apply:
New Member - $20.00 per family (annual renewable membership is due in July)
Renewing Member - $20.00 per year
I do NOT have Internet Access
I do have Internet Access
Payment Method: Cash Check PayPal (Option given when form is submitted)
Persons diagnosed with Celiac Disease (may include age, especially if a child):
If mailing, ENCLOSE A CHECK FOR THE FULL MEMBERSHIP AMOUNT OF $20.00 payable to: GIG - Lone Star. If mailing check, please send to: GIG - Lone Star; Jessica Millsap, 2408 Pheasant Dr., Little Elm, TX 75068 (Home #361-563-4229 or email: membership@dfwceliac.org for questions). Amount prorated depending on month you join.
Share with us about your diagnosis experience or make suggestions for programs / events:
We value your membership! We hope we are and have been responsive to your needs. We appreciate your suggestions and ideas for programs. Mentor services are available. Please check our website or ask if interested.
Notes: Lone Star is affiliated with GIG (Gluten Intolerance Group, http://www.gluten.net). You may join this national organization and receive its publication; go to its website for details
I understand that my name, address, phone and e-mail information will be posted on our secure Lone Star Web Site with password protected Member Login and listed on a member roster given to members only.
|