Membership

Membership in the Ostomy Association of Southern Jersey is open to all persons interested.

Members receive "Insights", our monthly newsletter.

Members and non-members can also attend monthly meetings at the Virtua Memorial Hospital of Burlington County

Name _____________________________________________
Address _____________________________________________
City ________________________________________________
State ____ Zip ____________________
Phone# ____________________________
E-mail Address _____________________________

To help complete our records, please answer the following:
Check if you have:
____ Colostomy
____ Ileostomy
____ Urostomy
____ Continent Ileostomy
____ Continent Urostomy
____ Ileo Anal Pull Thru
____ Other (Specify)
____ Spouse/family member
____ Friend

Please check if your ostomy is TEMPORARY ____

Date(s) of Ostomy surgery ______________
Date of Birth _______________________

2008 Dues for NEW MEMBERS ONLY $10.00

Please print this form and fill it out. Mail the form and your check made payable to
Ostomy Assocation of Southern Jersey to:

Ken Aukett
P.O Box 318
Collingswood, NJ 08108