Confirmation Page
Dear
ReturningMember_FirstNameNewMember_FirstNameCareGiver_FirstName,
Thank you for completing our membership application.
Please take a moment to
review the information you submitted below. If you see an error,
please go back to the Membership Application to make any necessary
corrections.
Please Check that your e-mail address is
correct:
ReturningMember_EmailNewMember_EmailCareGiver_Email
If your e-mail address is NOT correct, user
your Browser's "Back" command to return to the application and correct it, then
re-Submit the form. Thank you.
Please allow 24 to 48 hours for a response from Donita, our
Director of Membership Services. Our group is growing like nobodies
business so Please, be patient.
Please Check the information you provided is correct:
ReturningMember_FirstName
ReturningMember_LastName
ReturningMember_StreetAddress
ReturningMember_Address2
ReturningMember_City
ReturningMember_State
ReturningMember_ZipCode
ReturningMember_Country
ReturningMember_HomePhone
ReturningMember_Email_Permanent
ReturningMember_Email_Permanent_Confirm
ReturningMember_Email_Group
ReturningMember_Email_group_Confirm
NewMember_FirstName
NewMember_LastName
NewMember_StreetAddress
NewMember_Address2
NewMember_City
NewMember_State
NewMember_ZipCode
NewMember_Country
NewMember_HomePhone
NewMember_Email_Permanent
NewMember_Email_Permanent_Confirm
NewMember_Email_Group
NewMember_Email_group_Confirm
CareGiver_FirstName
CareGiver_LastName
CareGiver_Title
CareGiver_Organization
CareGiver_StreetAddress
CareGiver_Address2
CareGiver_City
CareGiver_State
CareGiver_ZipCode
CareGiver_Country
CareGiver_WorkPhone
CareGiver_HomePhone
CareGiver_FAX
CareGiver_Email_Permanent
CareGiver_Email_Permanent_Confirm
CareGiver_Email_Group
CareGiver_Email_group_Confirm
DOB:
Personal_DateOfBirth
Sex:
Personal_Sex
Have you ever had a
myelogram ?
Myelogram
If so, how many myelograms have you had? No_Myelograms
Have you ever had an Epidural Steroid Injection?
Epidural
If so, how many Epidurals have you had ?
No_Epidurals
Have you had Spinal Surgery ?
Surgery
If so, how many Spinal surgeries have you had ?
No_Surgeries
Have you been officially diagnosed with Arachnoiditis?
Arachnoiditis
If so, When where you diagnosed?
Diagnosed
Please tell us what
happened to you, Where is your Arachnoiditis? "My Arachnoiditis Story"
My_Arach_Story
You may return to the Membership Application form by using the
"BACK" button in your browser.
Circle of Friends With Arachnoiditis" (COFWA), "Arachniac", Arachnoiditis
Support and Information Association (ASIA), Arachniac's Pen Pals (APP) and/or,
any information, including email address, the Membership Roster names, the
Arachniac's Journal, maintained on this site, are copyrighted. Use of group and
service names, Roster or information without express written permission is
strictly prohibited.
[Webmaster]
Last Updated:12 June, 2007
