NYACK HOSPITAL AUXILIARY MEMBERSHIP FORM


We invite you to join the Nyack Hospital Auxiliary or renew your membership.
It is a wonderful way to combine community service and camaraderie.


Name _____________________________Mrs., Ms., Miss., Mr. New Renew
(circle choices)


Address __________________________________________________________

City __________________ State ______________________

Zip____________


Home Phone: ____________________

Business Phone: ___________________

E-mail address: _______________________

Birthday: ____________________
(day & month only)


I am interested in the following committees: Check your choices.

􀂉 Thrift Shop
􀂉 Production
􀂉 Hospital Volunteer
􀂉 Hospitality
􀂉 Gift Shop
􀂉 Programs/Special Events

Enclosed is my check for $15.00 _______.
Make checks payable to: Nyack Hospital Auxiliary
160 North Midland Ave., Nyack, NY 10960
(845) 348-2772 – Fax (845) 348-2776

You may download and print this files as:
Word Document or a PDF.