Lehigh Valley Active Life
| |Yes! I am interested in membership/renewal at Lehigh Valley Active Life. Check enclosed. Please update any new information. Thank you. |
|[pic] | |
| | |
|Membership/ | |
|Renewal Form | |
| | |
|LEHIGH VALLEY | |
|ACTIVE LIFE | |
|1633 West Elm Street | |
|Allentown, PA 18102 | |
|Phone: 610-437-3700 | |
|FAX Number: 610-437-6252 | |
| | |
| | |
| |Name: Mr. Mrs. Ms. |
| |Name: Mr. Mrs. Ms. |
| |Address: |
| |City: |State: |Zip: |
| |Phone Number: |
| |Email Address: Email Address: |
| |Birthdate: Birthdate: |
| |Township: |
| |Membership category’s: Circle One |
| |Life $200 |My additional donation of $ |
| |Regular: ($30.00) per year |Silver Sneakers ____ ____ ____ ____ |
| |Household: $30 1st person & $25 2nd person ($55) |
| |I am part of the PACE or PACENET drug assistance program -- Pace and Pacenet Eligibility 65 or older |
| |(income not to exceed $23,500 for 1 or $31,500 for 2) ___ yes ____ no |
| |IF NO WOULD YOU LIKE MORE INFORMATION ON HOW TO APPLY? ___ YES ____ NO |
| | |
| |The bylaws are located on the website in the “about Us” section under documents. Please review them. |
| |I have read the bylaws and will abide by them: -----yes -----no. |
| |Yes! I am interested in membership/renewal at Lehigh Valley Active Life. Check enclosed. Please update any new information. Thank you. |
|[pic] | |
| | |
|Membership/ | |
|Renewal Form | |
| | |
|LEHIGH VALLEY | |
|ACTIVE LIFE | |
|1633 West Elm Street | |
|Allentown, PA 18102 | |
|Phone: 610-437-3700 | |
|FAX Number: 610-437-6252 | |
| | |
| | |
| |Name: Mr. Mrs. Ms. |
| |Name: Mr. Mrs. Ms. |
| |Address: |
| |City: |State: |Zip: |
| |Phone Number: |
| |Email Address: Email Address: |
| |Birthdate: Birthdate: |
| |Township: |
| |Membership category’s: Circle One |
| |Life $200 |My additional donation of $ |
| |Regular: ($30.00) per year |Silver Sneakers ____ ____ ____ ____ |
| |Household: $30 1st person & $25 2nd person ($55) |
| |I am part of the PACE or PACENET drug assistance program – Pace and Pacenet Eligibility 65 or older |
| |(income not to exceed $23,500 for 1 or $31,500 for 2) ___ yes ____ no |
| |IF NO WOULD YOU LIKE MORE INFORMATION ON HOW TO APPLY? ___ YES ____ NO |
| | |
| |The bylaws are located on the website in the “about Us” section under documents. Please review them. |
| |I have read the bylaws and will abide by them: -----yes -----no. |
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