2ndwind.org - Second Wind Lung Transplant Association.

Secondwind Membership Application

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

STEP ONE:

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

Disease type/diagnosis: Required

Transplant Center: Required

Support Person(s)/ Relationship: Required

Transplant Status: Required

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

Date of Transplant: Required if Transplanted
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 - Personal & 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 publishes a Member Directory of recipients and candidates which is available on our web site to all members in a password protected area. The Directory includes the names and addresses of all members who have agreed to allow their names to be published. 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.

Please let us know if we can print your name in our directory.
I Agree to allow the information I provided on my membership applicaton to be published in the Second Wind Member Directory on the Member Search page of the web site.

We offer two options for paying dues.

1. The first is your PayPal account.

Personal & 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.
23609 Talbot
St. Clair Shores. MI 48082

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.