Join If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Type of Application: NewRenewal First Name * Last Name * Email * Address * City * State * Choose a state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Home Phone * Work Phone Fax Number Disease Type / Diagnosis None Alpha 1 Antitrypsin Def. Asthma Bronchiectasis Chronic Bronchitis Cystic Fibrosis Chronic Bronchitis and Chronic Obstructive Pulmonary Disease (COPD) COPD Emphysema Goodpasture's Syndrome Idiopathic Pulmonary Fibrosis Idiopathic Pulmonary Hemosiderosis Obliterative Bronchiolitis Prim. Pulmonary Hypertension Pulmonary Fibrosis Sarcoidosis Sec. Pulmonary Hypertension Wegener's Granulomatosis Date of Birth (mm/dd/yyyy) Transplant Center Support Person(s)/ Relationship Transplant Status Other Single Lung Recipient Bilateral Lung Recipient Heart/Lung Recipient Waiting List Investigating Transplant Support Person(s) Health Professional Transplant Coordinator Social Worker If you are a transplant recipient, please furnish the following: Date of Transplant (mm/dd/yyyy) Transplant Number If you are currently on the waiting list for a transplant, please furnish the following: Date Listed (mm/dd/yyyy) Select 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 the amount belowI am requesting a waiver of my annual dues for the reason belowI am not requesting either Enter Dollar Amount for your reduced annual dues Enter your reason to have your annual dues waived 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. Check below if you do not want your membership information made available in the on-line member directory or in the Airways publication unless written permission is provided. I request my Second Wind information be held confidential.
