Membership Application

Instructions: After completing this form, click the button on the bottom of the page to print. If you prefer, print the page and fill it out by hand. Mail completed form, along with your generous gift of support, to

Health Outreach to the Middle East
P.O. Box 711109
Houston, TX 77271

Please mark all that apply

I would like to become a member of H.O.M.E.

Annual Membership Dues for H.O.M.E. are $100 per person (students may pay a reduced rate of $10). We request that you submit your dues payment, along with your application, payable to "Health Outreach to the Middle East." Dues and donations are tax deductible; you will be mailed a receipt for tax purposes.

Enclosed is my one-time gift of     $

I would like to make a pledge of   $   per month for     months.

Please provide us with the following information:

Title:   First Name(s):    Last Name(s): 

 Address 1: 

 Address 2: 

 City:   State/Province:   Zip/Postal Code: 

 Country: 

 Phone:   Email: 


Print Form

Health Outreach to the Middle East
P.O. Box 711109
Houston, TX 77271