Date _____________________

Name _____________________________________________

Address ___________________________________________

City ______________________________________________

State _________________________ Zip ________________

Home Phone _______________________________________

Business Phone _____________________________________

Email Address ______________________________________

Parish/Synagogue ___________________________________

New Member

Renewing Member

$ 10 Regular Membership

$ 25 Contributing Membership

$ 50 Sustaining Membership

$100 Patron Membership

$200 Life Membership*

Please contact me to discuss opportunities.

 

* - Your name will be placed on a Roll of Honor

in the hospital. Please print your name as you would

like it to appear on our life membership plaque.

Please make your check payable to : Women's Auxiliary of Saint Francis

Hospital and Medical Center