Cushing’s Understanding Support & Help Organization
Application For All State & Locality Representatives

Please Print Information

Full Name___________________________________________________________________________________________________

Home Address_______________________________________________________________________________________________

City_________________________________________________State____________________Zip____________________________

Mailing Address___________________________________________City___________________State________Zip_____________

Home Phone ______________________________ Cell Phone ________________________ Work Phone ______________________

Employer________________________________________________ Address____________________________________________

City ___________________________________________State_____________  Zip__________  Position_____________________

Have you been diagnosed with Cushing’s?  Yes____No____ What Type?_______________________________ pituitary, adrenal etc.

Year of diagnosis __________________________ Surgery Yes________ No________     Are you cured? Yes _______ No________

Anyone in your family been diagnosed with Cushing’s? Yes____ No ___What Type?_____________________ pituitary, adrenal etc.

If you answered yes to the last question please answer the following questions for the family member. 

What is your relationship to this family member? He / She is my ____________________________________ sister, child, parent, etc.

.Name _____________________________________________Home Phone___________________ Other Phone ________________

Address________________________________________City__________________________State__________Zip______________

Year of diagnosis ________________ Surgery Yes__________ No__________  Are they cured?   Yes ___________ No___________

In your own words give a brief description of why you desire to be a State and or Locality representative for Cushing’s Understanding Support & Help Organization.  You may use a separate sheet of paper if needed.

I ____________________________________________________________________request to be considered as State and or Locality
Representative for the Cushing’s Understanding Support & Help Organization (CUSH)

State or Locality _____________________________________________ my home residence is in or within 100 miles of this locality.

I am a CUSH member in good standing and my dues will be kept up to date while serving as State and or Locality Representative.

I understand that by becoming a Representative for CUSH, I agree to host and organize a meeting or luncheon at least once per year within my State or Locality.  All meetings, luncheons, or any representation of CUSH will be pre-approved by CUSH.   I will not distribute any literature, video, audio material or any such representation of CUSH without prior approval from the CUSH Executive Directors.

I will not incur any charges or expense that I expect CUSH to pay for unless it has been pre-approved by the CUSH Executive Directors.

Occasionally doctors, medical professionals, Cushing’s patients or others within the state or locality in which I represent may need to be contacted. I agree to be the contact person if asked to do so by CUSH.  I will not be expected to pay for long distance phone charges or postage if I am asked to be a contact person.  I will not contact any medical professional, individual or facility on behalf of CUSH unless I am asked to do so by CUSH.  I will receive written instructions from CUSH for any such contact.

Cushing’s Understanding Support & Help Organization is a non-profit organization committed to bringing information regarding Cushing’s, and all its related illnesses into public awareness. As a representative for CUSH, I will not give medical advice to anyone on behalf of CUSH, as we are not medical authorities.  If I’m asked a medical question I will advise the person to seek information from a medical professional.

CUSH is not responsible for any accidents, injuries, actions and or occurrences directly or indirectly that are incurred as I represent the CUSH organization. It is my sole responsibility to make this known to any and all specific meeting and or luncheon attendees.

If for any reason the CUSH Board of Directors feels that it is deemed necessary to withdraw my title of state and or locality representative, a vote will be deemed as an order and in such case majority vote will rule.

I have read and understand both pages of the application, guidelines and expectations to become a State and or Locality representative for the Cushing’s Support & Help Organization.  I have been given a copy or have made a copy for myself of the guidelines and expectations. I agree to all contained within and hereby submit my completed application.

Applicants Signature______________________________________________________________ Date________________________

Below is for CUSH use only:

Date application was received ______________________________________ Date of vote__________________________________

Approved  Yes _____________________No_____________________            Date to start__________________________________

NOTE: CUSH secretary, if applicant is not approved please briefly state the reason why and send a copy to all Board Members for their files.  A print out of the meeting can replace the statement from the secretary, if the vote is held at an online meeting.

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