ARACHNOIDITIS INFORMATION & SUPPORT

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 COFWA Membership Application

COFWA (Circle of Friends with Arachnoiditis) is here for support of those who suffer from or know someone with arachnoiditis. COFWA was founded to provide education, friendship, caring, sharing, and insight to questions and concerns with living and coping with arachnoiditis.

As a private, online support group, COFWA functions almost exclusively on the Internet through e-mail with the utilization of listserv e-mailing services provided by YahooGroups' s (the largest on-line e-mail service provider in the world today). Our members are able to send and receive messages of information, support, caring and sharing.

The emails sent are sometimes pleas for help, requests for information or asking for support during a difficult period, sharing what it's like to live with arachnoiditis, and at times just friendly conversations with someone who knows what you are going thru and even a joke or two.

YahooGroups provide COFWAs members additional amenities including our own privet "chat" room where you can "Chat" with other COFWA members. The "Chat" room is closed to the public, as are all the activities / amenities within COFWAs YahooGroup. You will have access to our "Bookmarks" where we keep links to important information on the Internet, (i.e. Social Security Disability e^News, Workman's Compensation, Pain Management, Oxycontin). There is a "Physician Referral Database"; listing of Physicians our members have submitted, listed geographically by region, state and country. These are samplings of the amenities COFWA provides our members at YahooGroups.

Would you kindly respond to our questionnaire below. We review each new member to assure that COFWA is the kind of Support Group that meets your needs. ALL information is kept in strictest confidence. We are attempting to formulate profiles of arachnoiditis suffers with the information you provide. We realize some of the questions asked are of a personal, sensitive nature.  We ask that you complete as much information that you are comfortable in sharing.

If you are a returning COFWA Member, please provide your contact information in the section provided for you below so that we can confirm your information is accurate.

If you are a New Member, please provide your contact information in the section provided for you below.

If you are a "Care Giver", please provide your contact information in the section provided for you below.

We respect the fact that your personal information is privet.  Therefore the information you provide is kept in the strictest of confidence.  - Thank You!

 

  1. RETURNING COFWA MEMBERS, Please provide the following contact information:

    First Name
    Last Name
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country
    Home Phone

    Permanent E-mail Address
    Provided by your ISP

      (No Hotmail, Yahoo Mail or other freebie type address)
    Re-Type E-mail Address  

    E-mail Address to be used
    for COFWA Group mail

    (Just type "Same" if the same as your permanent address )
    Re-Type E-mail Address
  2. NEW  APPLICANTS, Please provide the following contact information:

    First Name
    Last Name
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country
    Home Phone

    Permanent E-mail Address
    Provided by your ISP

      (No Hotmail, Yahoo Mail or other freebie type address)
    Re-Type E-mail Address  

    E-mail Address to be used
    for COFWA Group mail

    (Just type "Same" if the same as your permanent address)
    Re-Type E-mail Address
  3. CARE GIVER, Please provide the following contact information:

    First Name
    Last Name
    Title
    Organization
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country
    Home Phone
    FAX

    Permanent E-mail Address
    Provided by your ISP

      (No Hotmail, Yahoo Mail or other freebie type address)
    Re-Type E-mail Address  

    E-mail Address to be used
    for COFWA Group mail

    (Just type "Same" if the same as your permanent address)
    Re-Type E-mail Address
  4. Please provide the following personal information about yourself:

Date of Birth
Sex Male Female
  1. Have you ever had a myelogram ?

Yes No

  1. If so, how many myelograms have you had?

       

  1. Have you ever had an Epidural Steroid Injection?

    Yes No

  2. If so, how many Epidurals have you had ?


  3. Have you had Spinal Surgery ?

    Yes No

  4. If so, how many Spinal surgeries have you had ?


  5. Have you been officially diagnosed with Arachnoiditis?

    Yes No

  6. If so, When where you diagnosed?

    -- mm/dd/yy

  7. Please tell us what happened to you, Where is your Arachnoiditis? "My Arachnoiditis Story"


By submitting this membership application you agree to COFWA NETIQUETTE ACCEPTABLE USE GUIDELINES FOR GROUP POSTINGS

 

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Circle of Friends With Arachnoiditis" (COFWA), "Arachniac's", 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.

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Last Updated:12 June, 2007