Page 7 - Mended Hearts Chapter 200 Welcome Package (English Language Version)
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Mended Hearts Chapter 200
Membership Application
Membership includes subscriptions to the Mended Hearts quarterly
journal, HEARTBEAT, the bimonthly Chapter newsletter, Mending Ways,
and Mended Hearts insignia pins (one of individual membership and two
for family memberships). Please check the appropriate box below,
complete the requested information, and mail this form, along with your
check, to:
Mended Hearts Inc.
Northern Virginia Chapter 200
PO Box 897
Annandale, VA 22003
√ Membership Type Membership Dues Total
Individual -Annual Nat’l $20 + Chapter $10 $30
Family-Annual Nat’l $30 + Chapter $10 $40
Individual-Lifetime Nat’l $150 + Chapter $50 $200
Family-Lifetime Nat’l $210 + Chapter $50 $260
Both National and Chapter dues are required for membership.
Name: ____________________________________________________
(Last Name) (First Name) (Spouse’s Name)
Address: ___________________________________________________
City: _________________________________ State: ____ Zip: ________
Phone: ___________________ Email: ____________________________
□I wish to support the work of Mended Hearts Chapter 200 with a
contribution of $_______.
