MENDED HEARTS - CHAPTER 9
MEMBERSHIP APPLICATION
MEMBER INFORMATION
Name
Chapter No. __9__ Member-at-Large _____
Address
Telephone (include area code)
Cellphone (include area code)
City
State
Zip
DOB
Retired (___) Yes (___) No
Occupation
Family Membership - Names of other member(s)
EMail Address
MEDICAL INFORMATION (Please fill out completely when applicable)
Name of Heart Patient
Name of Caregiver
Date of Surgery/Procedure
Hospital
Type of Surgery/Procedure
(___) PTCA
(___) MI
(___) Bypass (How many)_______
(___) Aneurysm
(___) Atrial Septal Defect
(___) Pacemaker
(___) Other __________
VALVE:
(___) Mitral
(___) Tricuspid
(___) Aortic
(___) Pulmonary
DUES
National Membership Dues include subscription to HEARTBEAT magazine and one insignia pin for an individual membership or two pins for a family membership. Select type of membership and include chapter dues (unless you wish to become a member-at-large).
NATIONAL DUES/AT-LARGE MEMBERSHIP
$  17.00 - New Single Members 1st Yr.
$  24.00 - New Family Members 1st Yr.
$  17.00 - Single Membership Renewal
$  24.00 - Family Membership Renewal
$150.00 - Lifetime Single Membership
$210.00 - Lifetime Family Membership
CHAPTER DUES
$   5.00 - New Single Members 1st Yr.
$   0.00 - New Family Members 1st Yr. (No Dues)
$   5.00 - Single Membership Renewal
$   5.00 - Family Membership Renewal
$  40.00 - Lifetime Single Membership
$  50.00 - Lifetime Family Membership
NATIONAL + CHAPTER DUES
$  22.00 - New Single Members 1st Yr.
$  24.00 - New Family Members 1st Yr.
$  22.00 - Single Membership Renewal
$  29.00 - Family Membership Renewal
$190.00 - Lifetime Single Membership
$260.00 - Lifetime Family Membership
Please make checks payable to: The Mended Hearts, Inc., Chapter 9.

Mail application and check to:
Janet Poitras, Treasurer
1 King Arthurs Way #5
Newington, CT 06111

To complete this application, please press the print button on your internet browser.
Complete it, enclose the applicable membership fee, and mail to the Mended Hearts treasurer listed above.  
 
 

The MENDED HEARTS VISITOR most often is the first contact a patient has with Mended Hearts, Inc. The support and encouragement you received by our Visitors,
are continued at our monthly meetings. We mail our newsletter to you as an invitation for you and your family to attend our meetings as our guests. We attempt to make our
meetings educational, informational, as well as entertaining. Please feel free to attend any of these meetings. Of course, we always hope you will enjoy us enough to want to
register and become a member of our group. We look forward to seeing you soon.
 
 
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