Ostomy Association of Metro Denver

Membership Dues are $30.00 Per Year

(Donations are also accepted in honor or memory, birthday or anniversary)

NAME                                                                                                                                 

ADDRESS                                                                                                                           

CITY                                                            STATE                                            ZIP           

PHONE                                   E-MAIL                                      

TYPE OF OSTOMY                    DATE OF OSTOMY                         

ON THE OCCASION OF                                   (If giving a donation)

Please make all tax-deductible checks payable to:

Ostomy Association of Metro Denver, Inc.  P.O. Box 480344, Denver, CO 80248-0344