MEMBERSHIP FORM
The American Celiac Family Support Group of RI
Date:
___________________________
Name: ___________________________
Mailing
Address:___________________________
___________________________
Phone:
___________________________
E-mail:
___________________________
( )
Membership Renewal $25
( ) New Membership $30
This includes a mailed/e-mailed new membership packet.
( ) I
would like to make an additional tax deductible donation to the American Celiac
Support Gr. in the amount of $____________.
( )
Total Amount Enclosed$__________
How
did you hear about this support group?
Please make your check payable to:
American Celiac Family Support
Group of RI