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Print form
and complete. Send to
HealthRewards
217 South Third Street
Danville, Kentucky 40422
_____Single membership
$20
_____Single plus
one membership (spouse, relative, friend)
$35
Member 1
Name:______________________________________
Address:____________________________________
City: _________________ State: _____
Zip _______
Date of birth:_________________________________
Social Security Number: ________________________
Telephone: __________________________________
Primary care physician: _________________________
Most recent admission: _________________________
Member 2
Name:______________________________________
Address:____________________________________
City: _________________ State: _____
Zip _______
Date of birth:_________________________________
Social Security Number: ________________________
Telephone: __________________________________
Primary care physician: _________________________
Most recent admission: _________________________
Method of Payment:
select one
____Check or money order
enclosed: Make payable to EM HealthRewards
____Visa _____Master
Card _____Discover Card
Amount: ____________________________________
Account number:______________________________
Expiration date:_______________________________
Signature: ___________________________________
Memberships are non-transferable and non-refundable.
Allow 4 weeks to receive official membership
materials.
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