Please print this page and mail the completed form to
Lynn Rainwater
5014 Gemsbuck Chase
San Antonio TX 78251-4380
Member's name ________________________________________ Do you have CD ( ) or DH ( )?
If you are the parent or spouse of someone with celiac disease, please list the family members who have celiac disease, their relationship to you, ages of celiac children, and whether they have celiac disease (CD) or dermatitis herpetiformis (DH).
Name _______________________________ child ( ) age (___), or spouse ( ) has CD ( ) or DH ( )
Name _______________________________ child ( ) age (___), or spouse ( ) has CD ( ) or DH ( )
Mailing Address _______________________________ City ______________________________
State _____ ZIP __________________ e-mail address _________________________________
Home phone (____) ____ - ________ Cell (____) ____ - ________ Work (____) ____ - ________
Name of doctor who is knowledgeable about celiac disease _________________________________
Other autoimmune diseases __________________________________________________________
Note: To protect your privacy, we do not publish your medical information in the roster or in the newsletter.
Annual year dues $20.00. Make check payable to Alamo Celiac GIG
So that members may contact one another, Alamo Celiac prints a roster with members' names, addresses, phone numbers, and e-mail addresses. The roster is distributed only to members and is not shared with any other sources. New members are also listed in the newsletter that is sent to members, our medical and dietitian advisors, and selected editors of other celiac support group newsletters. You may request to not have your information included in the roster or in the newsletter.
Do not include my information in the roster ( ) or the newsletter ( ).