Broward Ostomy Association Membership

If you wish to be a member of BOA, dues are $10.00 per year from January 1st to December 31st and includes receiving our monthly newsletter, the Broward Beacon. Please make checks payable to BOA and mail to: Mr. H. Lynn Ward, 1704 N 32nd Ct Hollywood FL 33021-4427

Name _________________________ Age ____ Year of Surgery________

Street _________________________ Apt. ____ Type of Ostomy________

City _________________________ Zip _______ Phone (___) _________

e-mail address: _________________________

__ I am an ostomate. I would like to become a dues paying member.

__ I am also enclosing a contribution for BOA.

__ I am an ostomate and would like to become a member but cannot afford dues at       this time. (This information is kept in the strictest confidence.)

__ I would like to become an Associate Member (non-ostomate).