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Air St. Luke's Gift Membership For New Member

Cost: $60 - First Year
(Membership renewals are $55 / year)

Gift Membership:

One Time Gift Membership
Annual Gift Membership (Your credit card will be charged for this year's membership but a bill will be sent to you for subsequent years membership.)

Gift Membership From:
* Required Information

First Name: * Last Name: *
Phone: *

Membership Recipient:
Primary Member Information
* Required Information

A gift certificate and membership information packet will be mailed to the shipping address specified on the next page.

First Name: * Middle Name:  
Last Name: *
Date of Birth: (mm/dd/yyyy) when available
Address: *
City: * State: * Zip: *
Phone: *
E-Mail:  
 
Start Date: optional (mm/dd/yy)
  Memberships will be activated 3 business days after
processing your order, unless a later start date is specified.
   
  How did you Hear About Air St. Luke's Membership?
   
  If Other:

 

Additional Family Members
Qualifying family members include spouse and any unmarried dependents under the age of 23 that can be claimed on recipient's income tax return.

This information is not required. Please enter only as much as you know. The gift recipient will be contacted to confirm the additional family members on their membership.

Family Member 1
First Name:		 Middle Name:
Last Name:
DOB:
Relationship: If Other:
   
Family Member 2
First Name:		 Middle Name:
Last Name:
DOB:
Relationship: If Other:
   
Family Member 3
First Name:		 Middle Name:
Last Name:
DOB:
Relationship: If Other:
   
Family Member 4
First Name:		 Middle Name:
Last Name:
DOB:
Relationship: If Other:
   
Family Member 5
First Name:		 Middle Name:
Last Name:
DOB:
Relationship: If Other:
   
Family Member 6
First Name:		 Middle Name:
Last Name:
DOB:
Relationship: If Other:
   
Family Member 7
First Name:		 Middle Name:
Last Name:
DOB:
Relationship: If Other:
   
Family Member 8
First Name:		 Middle Name:
Last Name:
DOB:
Relationship: If Other:
   
Family Member 9
First Name:		 Middle Name:
Last Name:
DOB:
Relationship: If Other:

How did you Hear About Air St. Luke's Membership?
If Other:

Questions? Call an Air St. Luke's representative at 1-800-822-1616
or 706-1000 if calling from the Boise area.


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