| MEMBER INFORMATION | |||||
Name |
Chapter No. __9__ Member-at-Large _____ | ||||
Address | Telephone (include area code) | ||||
City |
State | Zip | |||
DOB | Retired (___) Yes (___) No | Occupation | |||
Family Membership - Names of other member(s) | |||||
| MEDICAL INFORMATION (Please fill out completely when applicable) | |||||
Name of Heart Patient | |||||
Date of Surgery/Procedure | Hospital | ||||
Type of Surgery/Procedure | |||||
(___) PTCA |
(___) Atrial Septal Defect | VALVE: | |||
| 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). | |||||
$24.00 - New Family Members 1st Yr. |
$ 22.00 - New Single Members 1st Yr. | ||||
| Please make checks payable to:
The Mended Hearts, Inc., Chapter 9. Mail application and check to: 79 Belknap Road West Hartford, CT 06117 | |||||
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.