Membership Form

 

We are pleased that you are interested in joining UI Children's Hospital Heart Friends support group.

By completing and submitting this form you are granting permission for Heart Friends to add your name to a database. Your personal information will not be released to solicitors or advertisers.

Please fill out the form as completely as possible.

Parent's Names:
Street Address:
City:
State:
Zip:
Email:
Child's Name:
Child's Birth Date:
Description of Heart Defect
Surgery Dates and Names
Local Physician/Cardiologist
These are the activities in which I am interested in participating. (Check all that apply)
Meetings
Annual picnic
Membership directory
Annual CHD Day party
AHA Go Red for Women event
AHA Johnson County Heart Walk
Golf Outing
Mentoring other families


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Last modification date: Thu Jan 6 13:12:45 2011
URL: http://www.uihealthcare.com /depts/uiheartcare/heartfriends/form.html