Ambassadors Enrollment Form

Ambassadors Enrollment Form

Please check level of membership

Junior (Free, Grades 9-12)

Active ($5.00)

Associate($10.00)

Life ($250.00)

Name:

Birthdate:

Address:

City:

State:

Zip:

Phone: (H) (W)

Emergency Contact:

Emergency Phone:

Educational Background

Occupation:

E-Mail:

Please indicate which interest groups you would like to join (hold down the ctrl key to select more than one)

Please send this application, along with your dues, to:

Clarion Hospital Ambassadors

One Hospital Drive

Clarion, PA 16214