Bushkill Emergency Corps

www.bushkillemergencycorps.com

Subscription Drive

ENROLLMENT FORM

     subscription cost $70.00                   

 

Make checks payable to:

 

Bushkill Emergency Corps                               

                      C/O PNC Bank                                                    

P.O. Box 4515                              

 Philadelphia, Pa, 19131-6515       

 

List all immediate family members residing with you:

 Authorization:

I authorize that payment of authorized Medicare Benefits or other insurance benefits be made on my behalf for any services furnished by this health service provider or supplier. I authorize any holder of medical information or documation about me to release to the Health Care Financing Administration and its carrier and/ or agents, as well as this health service provider, any information or documentation needed to determine these benefits or benefits payable for any service to me by this Health Service Provider now or in the future.

Full Name                                                              Age

1. ______________________________   ______

 

2. ______________________________   ______

 

3. ______________________________   ______

 

4. ______________________________   ______

 

5. ______________________________   ______

 

6. ______________________________   ______ 

 

Address ___________________________________________________________________________________

Signature X_____________________________         To validate subscription, form must be completed,

Print Name _____________________________         signed, and returned with payment of full amount.

Date __________________________________           Valid ONLY for persons listed.

 

Charge my:        (  ) Visa         (  ) Mastercard           (  ) Discover        (  ) American Express

Credit card# ___  ___  ___  ___  ___  ___  ___  ___  ___  ___  ___  ___  ___  ___

Expiration Date: ___ ___ / ___ ___          3 or 4 digit code on card back: ___  ___  ___  ___