Senior Advantage Program Application Form

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.)