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COPD International       Your International Support Network

You can learn to control this disease instead of letting it control you!


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To join, please fill in the following information:

First Name: Last Name:
Mailing Address:
Street Address (if different):
City: State: Zipcode: Country:
Phone #:: Cell Phone:
E-mail address:
Alternate E-Mail Address:
A nickname that people know me by (enter only one name):     

Do You Live alone? Yes            No  
If No, with whom do you live?
Name: Relationship
Phone number (if different from above)

Emergency Contact Information -- Someone who does NOT live with you
Name: Relationship:
Phone #: Alternative Phone #:
E_Mail Address:

Comments or Special Instructions:
I understand that my participation in this program is strictly voluntary and does not replace my established, emergency contact protocol. . I authorize the list administrators to contact myself and/or my emergency contacts in the event I cannot be reached by way of my normal e-mail contact.

I agree to contact the list administrators of any changes in my personal, contact or other identifying information as soon as possible, including changes in e-mail address. I also agree to notify my emergency contacts of my participation in this program.


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Last modified: February 24, 2012

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