NYACK HOSPITAL AUXILIARY MEMBERSHIP FORM
We invite you to join the Nyack Hospital Auxiliary or renew your membership.
It is a wonderful way to combine community service and camaraderie.
Name _____________________________Mrs., Ms., Miss., Mr. New Renew
City __________________ State ______________________
Home Phone: ____________________
Business Phone: ___________________
E-mail address: _______________________
(day & month only)
I am interested in the following committees: Check your choices.
Enclosed is my check for $25.00 _______.
Make checks payable to: Nyack Hospital Auxiliary
160 North Midland Ave., Nyack, NY 10960
(845) 348-2772 – Fax (845) 348-2776