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Secondwind Membership Application

The application process requires two separate steps.
The first is the completion of the membership application below and the second is choosing a payment option.



STEP ONE:

New Application Renewal Application
First Name:  Required
Last Name:  Required
E-Mail address:
Address:
City: State:
Zip Code:
Country:
Home Phone: (Please include area code)
Work Phone: (Please include area code)
Fax Number: (Please include area code)
Date of Birth: (Month/Day/Year)

Disease type/diagnosis:

Transplant Center:

Support Person(s)/ Relationship:

Transplant Status:

If you are a transplant recipient, please furnish the following:

Date of Transplant:
Transplant Number:

If you are currently on the waiting list for a transplant, please furnish the following:

Date Listed:


If you would like to join, please select a Membership Type


Class 1 - Individual & Family
Candidate and Recipient Operative patients and/or their primary support person. Annual dues are $25.00.

Class 2 - Associate
For a 501(c)3 non-profit organization. Annual dues are $35.00

Class 3 - Professional Membership
For any interested individual in the medical or health care field. Annual dues are $ 50.00.

Class 4 - Corporate Membership
Includes any individual representing a company that supplies medication,
equipment, material or services to patients with any respiratory disease.
Annual dues are $ 100.00.

Fees for individuals who join in the Class 1 may be waived or reduced based upon individual circumstances. If you are requesting either a waiver or reduction of the membership fee, you will still need to submit this form so that we can enter your information into our data base. A member of the board will contact you by phone to discuss your request.

Check the appropriate box below to indicate that you wish to have your annual dues waived or reduced and the portion of dues that you are able to contribute at this time.
I am requesting a reduction in my annual dues and can contribute
$.
I am requesting a waiver of my annual dues for the following reason.

Second Wind maintains an on-line Member Directory of Lung Transplant recipients and candidates which is available on our web site to all members in a password protected area. The Directory Includes Membership information of members who have agreed to have their information included. It is intended to be used for information and support purposes only. You will be able to access this area if your dues are current. Participating in the on-line Member Directory is voluntary.

Also, Second Wind publishes a newsletter, AirWays, which includes members names from time to time.

I request my Second Wind information be held confidential. This means that my membership information will not be made available in the on-line member directory or in the Airways publication unless written permission is provided.




STEP TWO:

We offer two options for paying dues.

1. The first is your PayPal account.
 Individual & Family
Associate
Professional
Corporate
2. The second is: fill out the above form, print this page and mail it in along with a check with your dues made payable to:



Second Wind Lung Transplant Association, Inc.
Vice President
2781 Chateau Circle
Columbus, OH 43221
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DISCLAIMER: The information provided in this site is for educational purposes only, and it is not intended nor implied to be a substitute for professional medical advice. Always consult your own physician or healthcare provider with any questions you may have regarding a medical condition.


For comments, suggestions or contributions, please contact . Copyright © 1996-2008, Second Wind Lung Transplant Association, Inc. All rights reserved.