Celiac Sprue Association (CSA), San Diego Chapter #57

Registration Form

About CSA Chapter #57: Our support group meetings are held every other month, and involve sharing information about Celiac Disease (CD) and Dermatitis Herpetiformis (DH), guest speakers, potlucks, and more. We also have a dining-out group and provide a bi-monthly newsletter. Further information about our group is on the website at www.glutenfreeinSD.org under “Support Groups”.

To join: Please fill out this membership form and include $15.00 per family for annual dues (January to December). Please make checks payable to: CSA San Diego Chapter #57. Any additional contributions in support of the work our chapter is doing will be greatly appreciated.

If mailing, please send to: Bill Foreman, 7112 Lantana Terrace, Carlsbad, CA 92011 .

New ______ Renewal _______ Date ___________________________

Name(s) ___________________________________________________________________________

Address ________________________________________________ City ______________________

Zip ___________ Phone ______________________ Email Address* _________________________
*Your email will only be used to make occasional announcements concerning our group.

Occupation (optional) _______________________________

Number of immediate family members with CD or DH in each age category:

1-10_____ 21-40______ 41-60______ 61+_____

Was the Celiac Disease medically diagnosed? _______ If so, in what year(s)? __________­­­­­­­_____

Do you or a family member have DH? ________

If you would prefer to receive your newsletter by email rather than mail, initial here ____________

Please check the area(s) in which you would be willing to help the support group:

Refreshments _____ Computer _____ Phone Contacts _______

Committee member _____ Other _____ (please write on back of this sheet.)

To receive Lifeline, a very informative quarterly newsletter, join our national organization – CSA/USA (www.csaceliacs.org, 877-272-4272). Send $33 (new member), or $25 (annual renewal) to:

Celiac Sprue Association
P.O. Box 317,
Omaha, NE 68131-0700