Become a moving force in the Chicago area's most innovative and comprehensive wellness organization for seniors. Participate in White Crane's wide range of meaningful services and classes. Meet new friends; learn new skills; discover additional ways to eat well and stay health.

(Please print clearly. Your card will be included within your next newsletter.)

Name:	Today's Date:
Date of Birth:
Address:
Emergency Contact and Number:
(Please Check) New Member	Renewing Member
Regular Member (I have enclosed a check for $15 for the Annual Fee) Gold Card Member (I have enclosed a check for $120 for the Annual Fee)
Please make checks payable to: White Crane Wellness Center	Mail to: White Crane Wellness Center 1355 W. Foster Chicago, IL 60640	For office use only Expiration Date: Check amount: Check number: In computer: