Home About Us Membership Benefits Join > Events News Resources	Become a Member Today! Fill out this form to become a Connections member today! Name:__________________________________________ Address:________________________________________ ________________________________________________ City:____________________________________________ State:___________________________________________ Zip Code:________________________________________ Day Phone:_______________________________________ Evening Phone:___________________________________ Email Address:____________________________________ Date of Birth:_____________________________________ Employer:________________________________________ Today's Date:______________________________________ Please print this form and mail it along with your payment of $20.00* to NEPA Women's Health Alliance Marywood University 2300 Adams Avenue Scranton PA 18509 *Seniors (60+) and employees of Marywood University, Maxis Health System, and Mercy Hospital receive a special discounted rate of $15.00.                 Last updated December 15, 2006 Copyright © 2007 NEPA Women's Health Alliance