Register Name Name * Street * City * State * – Select Province/State – Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Phone Number Email * Cell Phone Number Who has Celiac or DH in your family? Self Spouse Child Age of child if relevant Non-Celiac Gluten Sensitivity? Self Spouse Child Age of child if relevant Have you met with a dietitian? Yes No If yes, name of dietitian Name of Diagnosing Doctor (Optional) Date of Diagnosis Have you met with a mentor of the NCAT Chapter? Yes No If yes, please enter name below. If no, check to be contacted by our Newly Diagnosed Coordinator. Yes, I would like to be contacted Notes Pay Dues
