Printer friendly registration form

The ON/AVN Support Group Int'l Association, Inc.

Membership

Registration F

orm - printer friendly version.

Please

copy/paste and complete form in your e-mail program and put "Membership"

and

your name

in the

subject line, then

please

e-mail to:

lastar@osteonecrosisavnsupport.org

Click

on link

All fields marked with an asterisk ( * ) are required fields.

______________________________________________

First Name:

* Last Name:

Address/Street:

* City:

State:

* Zip:

Home Phone:

Email:

(or mark "none", if none)

If you have a Web site, please list your

URL:

Year of Birth:

Please check mark any or all that apply to you:

I have AVN of:

One hip ____ both hips ____

One knee ____ both knees ____

One shoulder ____ both shoulders ____

One ankle ____ both ankles ____

Other sites _____

I am presently under a doctor's care for my AVN ____

I do not have AVN but want to learn more about it ___

I was diagnosed within the past 12 months _____

I am a friend/loved one for someone with AVN ____

I am seeking treatment for my AVN ____

Please feel free to tell us why you would like to join our group

Thank you for taking the time to fill out and submit our membership application form. Your personal identifying

information will not be shared with any other group, organization, or agency. However, we do reserve the right to

collect and save data on AVN for future research projects and your submission of this form is your permission

for us to collect/save your data on your AVN. You understand that there is no cost, fee, or dues to join our

support group; but that is subject to change in the future. Anyone who is interested at all in AVN is more than

welcome to join us.

Revised:

02/07/08

If you prefer, you may send us your registration form via regular mail to:

                                                   The ON/AVN SGIA, Inc.
                                                   Box 118
                                                   8500 Henry Ave.
                                                   Philadelphia, PA 19128