Membership Application
Please choose one of the annual membership options below:
______ Patient Member - $20.00
______ Physician Member - $30.00
________Additional tax-deductible donation
Name ________________________________________________________________
Address ______________________________________________________________
City, State, Zip _________________________________________________________
Phone (home) ______ __________________________________________________
(work) ______ ___________________________________________________
Email ________________________________________________________________
Sharing Network
”The Sharing Network”© is a great way to make a difference in another thyroid patient’s life as well as your own. Members of the Foundation are encouraged to join this program for mutual one-on-one exchange. Please consider joining today!
“My years as a medical practitioner, as well as my own first-hand experience, have taught me how important self-help groups are assisting their members in dealing with problems, stress, hardship and pain…Today, the benefits of mutual aid are experienced by millions of people who turn to others with a similar problem to attempt to deal with their isolation, powerlessness, alienation, and the awful feeling that nobody understands.” --C. Everett Koop, M.D. (1992) ◄
□ Check here if you wish to join the Sharing Network and indicate your diagnosis:
□ Hypothyroid □ Hyperthyroid □ Graves’ Disease □ Hashimoto’s Thyroiditis □ Thyroid Cancer □ Thyroid Eye Disease □other (_________________)
Today’s Date:__________________________________________________
Signature: _____________________________________________________
Your contact information will ONLY be shared with other AFTP patient members.
MAIL TO:
American Foundation of Thyroid Patients
P. O. Box 572472
Houston, TX 77257
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