Information for COPD Support groups for the benefit of the COPD patient
         

        

Membership Information Form
The following information will be available in the Members Directory

Name of Organization:
Mailing Address:
    City: State: Zipcode: Country:
The public's Contact person
or email box :		 Name:
Email:
Website URL (Leave Blank for None)
Category: International:    National:    Regional:    Local:
Support for: COPD Patient:       Caregiver:       Family/friends:   
Professionals:       Other interested individuals:
Types of support
that you provide:		 Email Lists:
Newsletter: weekly:       Monthly:         Other:
Chat Rooms:
Message Boards:
Reference Area:
Special support areas
      Quit Smoking Support:
      Exercise:
      Daily watch program for those alone:
Meetings/Luncheons:
       How often:
       Location:
Other types of support:
Short Description:
50 words maximum		 NOTE: This is what the
visitor will see first.
Long Description:

 

The following information will not be available in the directory.
Submitted by: Your first and last name
Your email address:  
Your Council Delegates: Select up to 3 who will be on the email list
 Name:
Email:
Name:
Email:
Name:
Email:

 

The following Statistics will never be divulged as individual numbers. 
They will only be used as a part of the total to indicate the scope of the
COPD Council's ability to reach out to the COPD Community.
Your Data:

Note: This is optional,
but can help the
Council help you and
your members by indicating
overall strength
 

 Members:
List subscribers:
Newsletter subscribers:
Website visits:per month
Other Data:

 
Comments:

Your feedback
is appreciated.

Thank you for your submission.
It will be reviewed and should be online
within the next 24 - 48 Hours