NEW MENDED HEARTS

MEMBERSHIP FORM
LOCAL CHAPTER AND NATIONAL
MEMBERSHIP
NEW MEMBERRENEW MEMBERSHIP
Name
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date
MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Check all that apply ( I am a)
Heart PatientCaregiverPhysicianRNHealthcare EmployeeOther
PLEASE BE A SUPPORT VOLUNTEER
I want to be a MH support volunteer:
LOCAL CHAPTER 350 DUES
ASSOCIATE Amount
PARTICIPATING MEMBER $10 SINGLE/ $15 FAMILY Amount
DONATION Amount
TOTAL Amount
ALL MONEY DONATED TO CHAPTER 350 IS USED FOR HEART PATIENT ENCOURAGEMENT AND EDUCATION AND FOR SAVING LIVES.
CHOOSE NATIONAL MEMBERSHIP LEVEL
INDIVIDUAL NATIONAL MEMBERSHIP
ASSOCIATE FREE ---* Can attend any chapter meeting * Can join online communities * Can access Member Portal * Receives the National e-newsletterINDIVIDUAL $20---* All of the benefits of an Associate Member, PLUS * Membership Card * Car Decal * One-time 5% off coupon for purchase from the MH store * One year annual subscription to Heartbeat magazine ($30 value)BRONZE $45--* All the benefits of a Full Individual Member, PLUS * Membership Pin * Choice of Drawstring Backpack or * 5% off registration of any National (not regional) MH/MLH Conference or SymposiaSILVER $100-- * All the benefits of a Bronze Member, PLUS * A Stainless Steel Mended Hearts Travel MugGOLD $250--- * All the benefits of a Silver Member, PLUS * A Red Fleece Blanket * 10% off registration of any National Conference or CHD SymposiumHEART OF GOLD LIFETIME SPONSOR $1500--* All the benefits of a Gold member FOR LIFE, PLUS * 15% off registration fees at National MH/MLH Conferences / Symposia * Recognition in the next Heartbeat magazine after enrolling in the Heart of Gold Lifetime Sponsorship, in all special Heartbeat issues, and on our website’s list of Heart of Gold Lifetime Sponsors
FAMILY NATIONAL MEMBERSHIP
FAMILY MEMBERSHIP $40--* All of the benefits of an Associate Member, PLUS * Membership Cards for all the members of the family * 2 Car Decals * Each family member receives a one-time 5% off coupon for purchase from the MH store --only one coupon per order * One year annual subscription to Heartbeat magazine ($30 value)BRONZE FAMILY MEMBERSHIP $75--* All the benefits of a Family Membership, PLUS * One Membership Pin per member * Choice of Drawstring Backpack or * 5% off registration of any National (not regional) MH/MLH Conference or Symposia
Family Member #1
SpouseChildHeart PatientName
Family Member #2
ChildHeart PatientName
Family Member #3
ChildHeart PatientName
NATIONAL MEMBERSHIP DUES
Chosen Membership Dues blanks
Donation to National blank
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Note: National memberships are tax deductible less $10.00. Lifetime sponsorships are 100% tax deductible.
THANK YOU SO MUCH FOR JOINING MENDED HEARTS
Total Due Local + National
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MEMBERSHIP FORM

LOCAL CHAPTER 350 DUES

CHOOSE NATIONAL MEMBERSHIP LEVEL

NATIONAL MEMBERSHIP DUES

THANK YOU SO MUCH FOR JOINING MENDED HEARTS