LOUISIANA DIABETES FOUNDATION
DONOR MEMBER APPLICATION

I want to be a part of the solution to help those with diabetes, especially in Louisiana!

Name (please print) ________________________________________________________________ Address__________________________________________________________________________ City__________________________________________State__________Zip__________________ Phone (_____)_____________________Fax (_____)__________________________ E-Mail _________________________________@____________________________

Donation includes immediate family residing together:
Donor Member      - (  ) Any amount
Sustaining Member - (  ) $100 and will make continued donations
Foundation Member - (  ) $1,000 minimum

Print and mail with check to:
LOUISIANA DIABETES FOUNDATION
4050 N. Maiden Drive
Baton Rouge, LA 70809