Chapter 28 Join

THE MENDED HEARTS, INC. CENTRAL VIRGINIA CHAPTER #28
MEMBERSHIP APPLICATION

Name__________________________________________________ Birthday (Day/Mo.)___/___

Address______________________________ Apt.#_____ Home Phone (_____)_____________

City_______________________ State_____ Zip________ Work Phone (_____)_____________

Type of Surgery/Treatment____________________________ Date of Surgery/Trmt.___/___/___

(Names of members celebrating their surgical anniversaries and years since surgery are printed in the newsletter. If you do not want yours to be in the newsletter, please call the chapter at 804.741.3893.)

Occupation_________________________________(Check if retired___)

Name of Spouse_________________________ Birthday (Day/Mo.)___/___ Anniversary___/___

Email Address_________________________________________________________________

We need volunteers to make a difference in heart patients' lives.

I am interested in:
____Visiting patients ____Committee work ____Telephoning
____Special events ____Driving members to meetings ____I will need a ride to meetings

Membership is open to people who have had heart surgery or heart disease, their families, and friends. Membership is for one year from the date
of enrollment and includes chapter newsletters, insignia pin, and the quarterly magazine Heartbeat. To be a member of a chapter you must be a
member of the national organization.)

Please select one of the following:

___Individual Membership: National and local chapter dues - Total $22.00

___Family Membership: National and local chapter dues - Total $34.00
(A family consists of two or more members in the same family sharing the same address.)

___Please send me the newsletter for one year even though I do not choose to join at this time. I enclose a $5.00 donation to help defray the cost.

___I enclose a donation to support the work of The Mended Hearts, Inc.

National Lifetime Memberships are available. Please contact the treasurer.

Please make your check payable to MENDED HEARTS CHAPTER #28.
Please print this form and mail it with your check to our treasurer:
MHI Chapter 28, PO Box 70234, Richmond, VA 23255-0234

To print the application you should be able to tell your printer to print page 1 only.
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"It's great to be alive - and to help others!"
Last updated June 7, 2008.
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