Celiac Sprue Association of Greater Chicago (CSA/GC)

Chapter #19 of CSA/USA, Inc.

P.O. Box 93, Arlington Heights, IL 60006-0093

Membership Application /Update (Please Print)

New Member __ Renewal __ Re-instatement ___

Last Name ______________________________________ First Name _________________________________ MI ______

Address _________________________________________ City __________________________ State ______ Zip ___________

Home Phone (_____) -____________________ Cell Phone (_____) - ____________________ Birthdate ____/____/_______

Work/other (_____) - _____________________ Fax (_____) - _________________________

E-mail* ________________________________________________

*Can CSA/GC send our newsletters via e-mail to save postage? Yes _____ No _____

Do you have Celiac Disease (CD) ___ Dermatitis Herpetiformis (DH) ___

Do you have a child/children with Celiac Disease (CD) ___ Dermatitis Herpetiformis (DH) ___

If you have children with CD or DH, please see back side of this form to find ways we can help.

How did you hear about us? ____________________________________________________________________________________

Are you a member of CSA/USA (our national organization)? Yes __ No ___

If not, would you like information about becoming a member? Yes __ No ___

Would you like a “buddy” to help you learn more about the gluten free diet and resources in your area? Yes ___ No ___

If you were/are pleased with your doctor, please provide his/her name and location so we can share with our membership.

Doctor name: __________________________________ City: __________________________ Specialty: _________________________

Signed: ________________________________________________ Date: __________________________

*Dues = New Member $20, Re-instatement $20, Renewal $15

*Dues ____________

Donation ____________

Other ____________ Notes ___________________________________________

Total $ ___________ Check # ___________________

NOTE: We do not sell or otherwise release any information to anyone outside CSA/GC. Your information is used only to provide help and assistance in dealing with concerns of the celiac community and planning appropriate events.

Our motto is "Celiacs Helping Celiacs.”

Please enclose your check with this application and send to:

CSA/GC Membership Secretary

P.O Box 93

Arlington Heights, IL 60006-0093

CONFIDENTIAL - CSA/GC OFFICE USE ONLY

Date Received __________ Check # ________ Check $ ___________ Check date ____________Membership # __________

Email added to contact list? Y N N/A

Membership Form 2009