Please mail completed form and your payment to:
Senior Advantage Program
Manatee Healthcare System
206 Second Street East
Bradenton, FL 34208
Questions? Call our office at 941-745-7548.
Please allow 3-4 weeks for processsing.
Thank you for joining Senior Advantage!
Manatee Healthcare System Senior Advantage Program
Application Form
Applicant's Name:_________________________________________ Date of Birth_______________
(Mo/Day/Yr)
Co-Applicant's Name:_______________________________________ Date of Birth_______________
(Mo/Day/Yr)
Address: _________________________________________________________________________
City: ___________________________________________/State____________/Zip______________
Telephone: ______________________________/ Email:____________________________________
Are you a Veteran? ____ yes ____ no Co-applicant? ____ yes ____ no
How did you hear about Senior Advantage? _____________________________________________
Method of Payment: Annual cost is $15.00 single/$25.00 per couple. OR Lifetime cost $45.00 single/ $70.00 per couple.
___ Check (Make checks payable to "MHS Senior Advantage")
___ Credit Card (We will contact you for credit card information by telephone when application is received.)
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