Healthy Choices Card Application Form

Healthy Choices for a Healthy Clearwater Card
Application Form

Fields in WHITE are REQUIRED

Fields in GRAY are OPTIONAL

Your Name: (Last, First, MI)
Address:		Unit # Note: If you live in an apartment or condo, the Post Office will not deliver your card unless you provide a unit number.
City:	State:	Zip Code:
Phone # (w/ Area Code):
Date of Birth: (mm/dd/yyyy)
Gender:
Your E-Mail Address:
Yes, I pledge to make at least one healthy choice each day. Please send me a Healthy Choices card that can be used for discounts at participating businesses.