I (we) would like to join the Greater Louisville Celiac Support Group Date:___________

NAME__________________________________/SPOUSE/PARENT______________________

ADDRESS______________________________________________________________________

CITY__________________________________________STATE______ZIP________________

TELEPHONE ____________________EMAIL______________________________________

CIRCLE ONE: ADULT TEEN CHILD New Membership $20.00 ________________

Renewal Membership $15.00 ________________

Please make your check payable to: CSA/GLCSSG, Chapter #68

Mail to: CSA/GLCSSG, P.O. Box 7194, Louisville, KY 40257-0194