Club 50 Plus



Enrollment Form

Sign up for Club 50 Plus at Cookeville Regional and start getting the support you need for a healthy and active lifestyle. Use this form to sign up today!

Date:September 9, 2010
Name:
Address:
City:
State:
Zip Code:
Phone Number:
Date of Birth:
Email:

Health topics: Please check all of the following areas of interest on which you would like to receive information or attend a class.
Heart/Vascular Disease
Diabetes
Arthritis
Exercise
Diet & Nutrition
Cancer
Gastrointestinal Disorders
Men's Health
Women's Health
Pulmonary/Lung Diseases
Drug Interactions
Geriatric Medicine
Neurology/Stroke
Orthopaedics
Sports Medicine/Physical Therapy
Rehabilitation Services
Home Health Services
Sleep Disorders/Treatment
Other:

How did you hear about Club 50 Plus? Please check all that apply.
Event
Newspaper
Radio
Friend
Web site
Other:

What are your favorite hobbies and/or pastimes?


What program benefits are you most interested in? Please check all that apply.
Education Classes
Social Activities
Volunteer Opportunities
Health Screenings
Physician Referral
Notary Services
Financial Counseling
Hospital VIP Services
Business Discounts
Support Groups
Member Newsletter

To help us with event planning, please let us know what works best with your schedule:
Daytime events or Evening events

What services at CRMC have you used?
Heart Center
Cancer Center
Women's Center
Sleep Center
Orthopaedics
Diabetes Center
Spine Center
Neurological
Other: