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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.

If you have questions about this program , please contact us at 
KIT@COPD-International.com