Privacy Statement – The information you give will remain confidential and will be used exclusively for this purpose. All information is confidential and will not be released to any group or organization outside of Baptist Health Care.

  Application Form

Fill out the following form to sign up online or use the link at the bottom of this page to print out the GoldenCare application:

First Name	*
Last Name	*
Mailing Address	*
Apt/Suite#
City / State	*   Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming   *
Zip Code	*
Phone	*  format: 123-456-7890
Email Address
Send me the Newsletter via email?	Yes No   *
Gender	Male Female   *
Date of Birth	*  format: 01/01/1111
Personal Physician
How did you hear about Golden Care?	Brochure Family Member Friend GoldenCare Newsletter GoldenCare Seminar HealthSource Hospital Signage Hospital(Staff) Hospital Volunteer Magazine Ad Newspaper Physician's Office Senior Expo   *

I've been a patient at:	Baptist Hospital
Baptist Manor	Gulf Breeze Hospital
Atmore Community Hospital	Jay Hospital

Thank you for taking the time to complete this GoldenCare Membership Application!