MENDED HEARTS - CHAPTER 9
MEMBERSHIP APPLICATION

MEMBER INFORMATION
Name
Chapter No. __9__ Member-at-Large _____
Address 1
Telephone (include area code)
Address 2
Cellphone (include area code)
City
State
Zip
Date Of Birth
Retired (___) Yes (___) No
Occupation
Family Membership - Names of other member(s)
EMail Address
MEDICAL INFORMATION (Optional - No application is denied based on medical information, age, or race.)
Name of Heart Patient (1)
Name of Heart Patient (2)
Date of Surgery/Procedure
Date of Surgery/Procedure
Type of Surgery/Procedure
Type of Surgery/Procedure
PATIENT (1)
(___) Angioplasty
(___) MI (Heart Attack)
(___) CABG (Bypass) (How many)_______
(___) Aneurysm
(___) Cath
(___)
PATIENT (1)
(___) Atrial Septal Defect
(___) Pacemaker
(___) Transplant
(___) Stent
(___) AFib Arrhythmia
(___) Other Arrhythmia
PATIENT (1)
(___) Valve Surgery
(___) Valve Transcath
(___) ICD (Defibrillation)
(___) R-VAD/L-VAD
(___)
(___) Other__________________
PATIENT (2)
(___) Angioplasty
(___) MI (Heart Attack)
(___) CABG (Bypass) (How many)_______
(___) Aneurysm
(___) Cath
(___)
PATIENT (2)
(___) Atrial Septal Defect
(___) Pacemaker
(___) Transplant
(___) Stent
(___) AFib Arrhythmia
(___) Other Arrhythmia
PATIENT (2)
(___) Valve Surgery
(___) Valve Transcath
(___) ICD (Defibrillation)
(___) R-VAD/L-VAD
(___)
(___) Other__________________
PATIENT (1)
        Many chapter newsletters include surgery/treatment
        anniversaries of members. Please indicate here if you
        are agreeable to having your name published in this way.

 (___) Yes (___) No (Signed)_______________________________
PATIENT (2)
        Many chapter newsletters include surgery/treatment
        anniversaries of members. Please indicate here if you
        are agreeable to having your name published in this way.

 (___) Yes (___) No (Signed)_______________________________
DUES
National Membership Dues: Includes subscription to HEARTBEAT magazine and one insignia pin for an individual membership or two pins for a family membership (must reside in same household). Select type of membership and include chapter dues (unless you wish to become a member-at-large). National dues are tax deductible less $10.00; Chapter and Lifetime Dues are 100% tax deductible.
NATIONAL DUES/AT-LARGE MEMBERSHIP
$  20.00 - New Single Members 1st Yr.
$  30.00 - New Family Members 1st Yr.
$  20.00 - Single Membership Renewal
$  3000 - Family Membership Renewal
$150.00 - Lifetime Single Membership
$210.00 - Lifetime Family Membership

Dues Summary:         National Dues $_______
                                   Chapter Dues $_______
                                             TOTAL $_______
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

I am joining as a non-heart patient:  (___) Physician   (___) RN
(___) Health Admin.   (___) Other Health Party   (___) Other
I am not prepared to join. Enclosed is a contribution of $_______
                                        For: (___) National   or   (___) Chapter 9
Please make checks payable to:
~            The Mended Hearts, Inc., Chapter 9.            ~

Mail application and check to:
                 Steve Livingston, Treasurer
                 501 Dzen Way
                 South Windsor, CT 06074


To complete this application, please press the print button on your internet browser. Complete information,
enclose the applicable membership fee, and mail to the Mended Hearts Chapter 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 at no cost. 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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