HealthyPlanet
Membership Application

Please fill out this application and mail with your check
(payable to HealthyPlanet) to:
HealthyPlanet, P.O. Box 163, Huntington, NY 11743

I WOULD LIKE TO JOIN . . .
Today's Date: 

First Name: 

Last Name: 

Address: 

City: 

State: 

Zip Code: 

Phone: 

Fax: 

Email: 

I'D LIKE TO HELP WITH . . .
 Anything needed      Monthly Phone Calling      Office Help (Huntington)

 Healthy School Lunch Program       Data Entry      Newsletter/Writing

 Core Group      Potluck Organizing      Advertising Sales Newsletter

 Distribution      Graphics/Artwork      Public Speaking

 Help with Mailings      Media/Public Relations       Fundraising

 Photocopying      Staff Table      Cooking      Research

 Computer Help      Health Partnership Program      Poster Distribution

TYPE OF ANNUAL MEMBERSHIP . . .
 New      Renewal

 BENEFACTOR $1000      SUSTAINER $500

 PROFESSIONAL $125      STUDENT/SENIOR $20

 FAMILY (includes 2 cards) $50      INDIVIDUAL $35

 *Monthly Pledge (*Send Me Authorization for Auto Payments)

TYPE OF PAYMENT . . .
 Check (payable to HealthyPlanet)      Credit Card

Type of Credit Card: 
Name on Credit Card: 
Credit Card Number: 
Expiration Date: 
Signature: 


(Family Level and Higher Receive 2 Discount Cards; Please allow 2-4 weeks for membership packet to arrive)

Return to Membership Page