Transplant Support Organization

Please Print This Page, fill it out and mail it with your tax-deductible contribution to:
T S O, 1154 Webster Avenue, New Rochelle, NY 10804

Participant Application: New Renewal

NAME(S)__________________________________________________

Street Address:_____________________________________________

City, State, Zip:______________________________________________

Daytime Phone: ________________________________

Evening Phone: ________________________________

Email address: ________________________________________________

PERSONAL INFORMATION (optional):
Date of Birth: __________________ Sex: _____ Marital Status: _______

Occupation: ____________________________________________

CANDIDATE / RECIPIENT INFORMATION - Please circle appropriate description.

Transplant Recipient	Transplant Candidate	Family Member
Donor Family Member	Interested Individual	Professional

Have you already had a transplant? Yes No

Number of Transplants ______

Type of Transplant(s) _________________________________________

Date(s) of Transplant(s) ___________________________

Time waited (or waiting) ______________________________________

Where did you (will you) have your transplant?

_______________________________________________________________

PARTICIPANT CATEGORIES & SUGGESTED CONTRIBUTIONS
Regular (Transplant recipient, transplant candidate, family member, donor family):

Individual Participant	$ 25.00
Family Participant (two members at same address)	$ 35.00
Additional participants at same address	$ 10.00 each additional
Additional participants at different address	$ 15.00 (first) $ 10.00 (additional)
Professional (Surgeon, Physician, Clinical Coordinator Nurse, Social Worker, Other)	$ 25.00

Additional optional voluntary contribution ( at your discretion ): $ _________

I would like to take an active role within TSO (please check all areas of interest):

_____Speaker _____Membership Drive _____Fund Raiser _____ Hospital Visitor

_____ Clerical _____Contributor _____Patient & Family Support

_____Newsletter _____Data Processing _____Other _____Sorry, too busy

Thank you for joining TSO and for your contribution!