Lone Star Celiac GIG Support Group
Membership Form

Today’s Date:   Web Site: DFWCeliac.org
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:
E-mail address:
Suggested Username(s) for website:
You will be sent a generic Password when your paperwork is complete. When you login for the first time, you will be prompted to change it 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 prefer to receive my newsletters by mail or
 I prefer to save mailing costs and receive the newsletter by using our secure web site Member Only Section.

Persons diagnosed with Celiac Disease (may include age, especially if a child):

ENCLOSED IS MY FULL MEMBERSHIP CHECK FOR $20.00 payable to: Lone Star Celiac GIG Support Group. If mailing check, please send to: Lone Star Celiac GIG Support Group; 1505 Amesbury, Richardson, TX 75082 (Home #972-235-8521 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: 
R.O.C.K. - Raising Our Celiac Kids - is an organization formed to specifically support families with diagnosed celiac children. See information in the newsletter or website (Kids Support Group) or contact Kelly LeMonds at leader@dallasrock.org or 972-489-9915..

Lone Star 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 Lone Star Web Site with password protected Member Login and listed on a member roster given to members only.

Signature ________________________________________________________________________