LEHIGH VALLEY HEALTH NETWORK

[Pages:2]Additional Membership Application (SECOND MEMBER INFORMATION)

TYPE OF MEMBERSHIP

SINGLE APPLICANT ($35) DOUBLE APPLICANTS ($60) (Residing at same address only)

FIRST MEMBER: MALE FEMALE

NAME: MRS. MS. MR. DR.

ADDRESS:

APT.#

CITY:

STATE:

ZIP:

HOME PHONE:

CELL:

EMAIL: (Will only be used to send information on news and events at LVHN)

DATE OF BIRTH:

/ /

AGE:

ARE YOU RETIRED: YES NO SEMI-RETIRED

DO YOU HAVE ANY MEDICAL CONDITIONS WE SHOULD BE AWARE OF? YES NO

If yes, please list:

EMERGENCY CONTACT NAME: HOME PHONE:

RELATIONSHIP: CELL:

The Senior Choice program is all about you. We'd love to hear your suggestions on how Senior Choice can best meet your educational, social and health lifestyle needs:

How did you hear about Senior Choice?

MEMBERSHIP DUES

ONE-YEAR SINGLE MEMBERSHIP: $35

FOR OFFICE USE ONLY

ONE-YEAR DOUBLE MEMBERSHIP SAME ADDRESS ONLY: $60

Effective Date

/ /

PAY BY CHECK TO: LEHIGH VALLEY HOSPITAL?HAZLETON FORWARD MEMBERSHIP APPLICATION AND CHECK TO:

Renew Date / /

SENIOR CHOICE ADVISOR, LEHIGH VALLEY HOSPITAL?HAZLETON

Senior Choice is a program of Lehigh Valley Hospital?Hazleton. Benefits may change without notice. Senior Choice reserves the right to deny or terminate the membership of any individual based on Senior Choice's sole discretion. Photos may be taken at various Senior Choice events to be used for Lehigh Valley Hospital? Hazleton publications and advertisements. If you do not wish to be photographed, please inform the Senior Choice advisor on the day of the event.

LEHIGH

VA L L E Y

H E A LT H

NETWORK

Senior Choice

700 E. Broad St. Hazleton, PA 18201

570-501-4000 hazleton

570-501-4000 hazleton

LEHIGH

VA L L E Y

H E A LT H

NETWORK

Senior Choice

A program for seniors from Lehigh Valley Hospital?Hazleton

570-501-4000 hazleton

Welcome to Senior Choice

Today many seniors ? and many soon-to-be seniors ? are living active, healthy lifestyles and continue to make valuable contributions to our society.

That's why Lehigh Valley Hospital?Hazleton developed Senior Choice. This program provides members with educational, social and healthy living opportunities to help you maintain your mental and physical vitality now and into the future. Specifically for people ages 55 and older, Senior Choice offers health and wellness programs, social activities, discounted programs and services, opportunities to develop friendships and more.

Becoming a senior doesn't mean life stops. It means a new life is just beginning. Senior Choice wants to be with you on that journey.

ANNUAL MEMBERSHIP FEE

Individual: $35/year Two members (residing at same address): $60/year

If you are 55 years of age or older and are interested in becoming a member of Senior Choice, please complete the attached application or contact the Senior Choice advisor at 570-454-4752.

For more information about upcoming Senior Choice activities, check out the online community health calendar at hazletoncalendar.

Membership Benefits

Membership in the Senior Choice program includes the following benefits:

HEALTH AND WELLNESS

free lunch-and-learn education programs free or discounted workshops and seminars free health screenings and wellness programs Discounted membership at the Health & Wellness Center

at Hazleton (specific times apply) free health plan and insurance counseling

SOCIAL

Special events (bus trips, holiday party, picnics) Access to discounted shows, parks and other activities

HOSPITAL

Hilltop Caf? dining at Lehigh Valley Hospital?Hazleton ? 15% discount on all meals

Volunteer opportunities at Lehigh Valley Health Network facilities

OTHER

free subscription to Healthy You magazine free Senior Choice newsletter Monthly calendar of events

Membership Application

TYPE OF MEMBERSHIP

SINGLE APPLICANT ($35) DOUBLE APPLICANTS ($60) (Residing at same address only)

FIRST MEMBER: MALE FEMALE (Second member: Complete application on reverse side.)

NAME: MRS. MS. MR. DR.

ADDRESS:

APT.#

CITY:

STATE:

ZIP:

HOME PHONE:

CELL:

EMAIL: (Will only be used to send information on news and events at LVHN)

DATE OF BIRTH:

/ /

AGE:

ARE YOU RETIRED: YES NO SEMI-RETIRED

DO YOU HAVE ANY MEDICAL CONDITIONS WE SHOULD BE AWARE OF? YES NO

If yes, please list:

EMERGENCY CONTACT NAME: HOME PHONE:

RELATIONSHIP: CELL:

The Senior Choice program is all about you. We'd love to hear your suggestions on how Senior Choice can best meet your educational, social and healthy lifestyle needs:

How did you hear about Senior Choice?

MEMBERSHIP DUES ONE-YEAR SINGLE MEMBERSHIP: $35

FOR OFFICE USE ONLY

ONE-YEAR DOUBLE MEMBERSHIP SAME ADDRESS ONLY: $60

Effective Date

/ /

PAY BY CHECK TO: LEHIGH VALLEY HOSPITAL?HAZLETON FORWARD MEMBERSHIP APPLICATION AND CHECK TO: SENIOR CHOICE ADVISOR, LEHIGH VALLEY HOSPITAL?HAZLETON 700 E. BROAD ST., HAZLETON, PA 18201

Renew Date / /

Senior Choice is a program of Lehigh Valley Hospital?Hazleton. Benefits may change without notice. Senior Choice reserves the right to deny or terminate the membership of any individual based on Senior Choice's sole discretion. Photos may be taken at various Senior Choice events to be used for Lehigh Valley Hospital? Hazleton publications and advertisements. If you do not wish to be photographed, please inform the Senior Choice advisor on the day of the event.

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