Gluten Intolerance Group of Greater Dallas
Membership Form

Today’s Date:  mm/dd/yyyy  
Name(s) of person(s) joining or renewing (may be one or more family members, one should be an adult):
 (Last,          First          Initial)
 
Address:  
City: State: Zip:
Home Phone: Work: Cell:   ex 972-333-3434
E-mail address:
 
Username for website: (required)
For new members, when your paperwork is complete, you will be assigned one of your suggested Usernames and a temporary  Password .  When you login for the first time, you will be prompted to change the Password  to something of your choosing.

Check all that apply:
New Member - $20.00 per family (annual renewable membership is due in July)
Renewing Member - $20.00 per year
I do NOT have Internet Access
I do have Internet Access

Payment Method:  Cash     Check     PayPal (Option given when form is submitted)

Persons diagnosed with Celiac Disease (may include age, especially if a child):
 
 
If mailing, ENCLOSE A CHECK FOR THE FULL MEMBERSHIP AMOUNT OF $20.00 payable to: GIG - Greater DallasIf mailing check, please send to: GIG of Greater Dallas;  Melanie Jennings, 9211 Pinewood, Dallas, TX 75243.  (Phone 214-228-5953 or email: membership@dfwceliac.org for questions).  Amount prorated depending on month you join.

Share with us about your diagnosis experience or make suggestions for programs / events:
 
 
We value your membership!  We hope we are and have been responsive to your needs.  We appreciate your suggestions and ideas for programs.  Mentor services are available.  Please check our website or ask if interested.

Notes: GIG of Greater Dallas is affiliated with GIG (Gluten Intolerance Group, http://www.gluten.net).  You may join this national organization and receive its publication; go to its website for details

I understand that my name, address, phone and e-mail information will be posted on our secure GIG of Greater Dallas Web Site with password protected Member Login and listed on a member roster given to members only.

Enter the Case Sensitive text from the graphic into the
text box on the right.  Then click Submit Form