under 18 years) Member's Signatu rgnaturc of legal gttatdtan if applicant under 18 years) Member's Address an 9 EASY —3-I 3 T 1/4ST 1\1`), 1\1\) Street City State Zip Code Home/Work/Cell #s email address' Cancer Center For Healing / Center for New Medicine By Approved and accepted this day of 20 . Ij