Membership includes subscriptions to the National Organization quarterly journal, HEARTBEAT and Mended Hearts insignia pins (one for individual membership and two for family memberships). Please make a print copy of this application, check the appropriate box below, complete the requested information, and mail this form along with your check made payable to Mended Hearts Chapter 94 to: The Mended Hearts, Inc., National Capital Area Chapter 94, 110 Irving Street, Room EB 1017, Washington, D.C. 22003.

Please Print Legibly:

Last Name: ________________________________

First Name: _____________  Spouse's Name: _______________

Address, City, State, Zip: ________________________________________________________________

Phone:  (         ) _____ — ____________  e-mail address: ___________________

Occupation: _______________   Retired:    Yes      No       Date of Birth: _________

Volunteer!  If you have some “spare” time help us help others fight heart disease. Volunteer!
I want to help by:   (   ) Visiting Patients  (   ) Office Help  

How did you learn about Mended Hearts?: ________________________________________________

_____________________________________________________________________________

(   )  I am not a heart patient but wish to support the work of Mended Hearts.
(   )  I am not prepared to join Mended Hearts but enclose a contribution of $___________.

Note: All Dues or Donations are Tax Deductible.

* Members may be victims of heart disease and/or other individuals who wish to assist in the purposes of this organization and have paid the required dues. Family memberships are encouraged. They include two or more members of an immediate family living at the same address. If applicable, include names and pertinent information for each family member on a separate sheet of paper. National membership is required for chapter affiliation – this application covers both.

Name of Heart Patient (if other than above): ___________________________________________

Name of Surgeon, Cardiologist, Internist, etc.: __________________________________________

Name and Address of Hospital: _______________________________________________________

Date(s) of Hospitalization or Surgical Procedures: _______________________________________

Select all that apply: