Fields in WHITE are REQUIRED
Fields in GRAY are OPTIONAL
(Last, First, MI)
Note: If you live in an apartment or condo,
the Post Office will not deliver your card unless you provide
a unit number.
Phone # (w/ Area Code):
Date of Birth:
Your E-Mail Address:
Yes, I pledge to make at least one
healthy choice each day. Please send me a Healthy Choices card
be used for discounts at participating businesses.