Signing up for a membership is as easy as 1, 2, 3...

1. Complete the form below.
2. Make checks payable to Kettering Health Network.
     (Cost is $10 Per Person)

Your Information
First Name:	M.I.:
Last Name:
Address:
City:
State:	AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY   Zip:
Home Phone:
Date of Birth:
Sex:	Male   Female
Would you like to be sent an email about screenings and events?	Yes   No   Email:              (Optional)

Your Spouse's Information
First Name:	M.I.:
Last Name:
Address:
City:
State:	AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY   Zip:
Home Phone:
Date of Birth:
Sex:	Male  Female

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