SUSQUEHANNA HEALTH SPIRIT OF WOMEN MEMBERSHIP APPLICATION FORM
Become a Susquehanna Health Spirit of Women member and you’re doing more than just joining a club – you’re helping yourself and your family lead healthier, more informed lives.
As a Spirit of Women member, you will enjoy a variety of benefits, including:
· Free or discounted admissions to Spirit of Women sponsored events and health screenings.
· Invitations to members only special events
· Membership loyalty card that will give you access to special offers from a variety of local businesses
· Free Susquehanna Health magazine
YES! I would like to become a member
Please enroll me in the Susquehanna Health Spirit of Women Membership Program
Mr. Mrs. Ms. Miss. Dr.
(please print)
Name
Address
City State Zip
Telephone Email
Date of Birth (month/day/year)
Are you a school district employee? YES NO
If yes, please list district and school______________________________________
Do you consider yourself a current Susquehanna Health patient/client? YES NO
If yes, which of the following services do you currently use?
Breast Health Emergency Room Imaging Pharmacy
Cancer Center Family Practice Lab The Birthplace
Cardiology Hospital OB/GYN Other
Number of children in your household under the age of 18
Do you prefer to receive your Susquehanna Health magazine via email U.S. mail
My interests:
Career/Education Childcare Cooking Fashion/Beauty
Crafts Relationships Gardening Health/Fitness
Other
By joining Spirit of Women and/or participating in Spirit of Women programs and events, I agree to waive any and all claims against Susquehanna Health, its employees, directors and officers, all sponsors, their representatives and any successors from any all claims or liabilities of any kind arising out of my participation in this program or any related activities. For Susquehanna Health privacy policy, log onto www.SusquehannaHealth.org.