A CDF Connection Group

Membership Form

Celiac Disease Foundation: Greater Phoenix Chapter
 

Name_________________________________________________________Date______________________________
 
(Parents’ name(s) if celiac family member is a child) ______________________________________________________

Street___________________________________________________________________________________________
 
City____________________________________________State______________________Zip Code_______________
 
Phone___________________________________ email address____________________________________________

Age of the celiac(s) ________________________________________________________________________________ 

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 us?_________________________________________________________________________
 
Have you already joined our parent organization, Celiac Disease Foundation?__________________________________
 
If so, when did you last pay dues? (month and year)______________________________________________________

We have an email group where celiacs can ask questions and offer comments about living with CD. Would you like for me to add you? (It is free and you can unsubscribe at any time.) _____________________________________

As a support group of volunteers, we are always glad to have others help out.  May we count on you to occasionally:

• Help with set-up prior to or clean-up after meetings?__________________________________ 

• Bring food to a meeting?________________________________________________________

• Help plan social events?________________________________________________________

• Mentor new celiacs?___________________________________________________________

• Serve on a short-term committee?________________________________________________

The work our group does is funded in two ways: 1) annual membership dues, 2) donations. Checks can be made out to
Celiac Disease Foundation for tax deductible purposes.
 
Upon joining, members receive copies of the guidelines that govern us; however, they are available to prospective members by request.
Please mail this form with check to Diane Lake 4142 W. Electra Lane, Glendale, AZ 85310. For any questions, email Diane at dlake41@cox.net.