Healthy Living Club: Application

Thank you for your interest in joining our exceptional club for a healthier community! Please complete the following Healthy Living Club application. Be sure to complete the information as it applies to you.

For more information, call (814) 889-2630 or (888) 313-4665. You can also e-mail our club representatives at hlc@altoonaregional.org.

This application is for regular or Gold Club membership. Must be 55 or older for Gold Club.

* Required fields.
Today's date:
*Name:	* First MI * Last Suffix
*Address:	Apt.
*City:
*State:
*Zip:
*Phone/Day:
Phone/Evening:
*Date of birth:	(Note: Date of birth needed to determine Gold Club eligibility)
Male     Female
Spouse's Name:	First MI Last Suffix
If you received an issue of Healthy Living Magazine in the mail, please enter the ID number from the mailing label:
Are you a "snowbird" or receive mail at a second address during part of the year? If so, please provide us with your second address and dates you wish to receive mail there.
Second Address:	Apt.
City:
State:
Zip:
Dates at this address:	TO