Membership Form
We are here for your support, please fill out the below form and let us know what we can do to help you. If you're interested in receiving a peer mentor, or being a peer mentor, please note this at the bottom of this form. After your form has been submitted we will send the information forward to Mended Hearts Nationals for submission and they will send you a membership pin and packet. Thank you for contacting Mended Hearts of Spokane.

There are many benefits to joining our organization!

6 issues of Heartbeat magazine annually.
Participation in Visiting/Direct Support programs.
Educational meetings and webinars on a variety of topics.
Access to private “member” Website.
Advocacy Opportunities.
Invitations to Regional and National educational meetings

Mended Hearts or Mended Little Hearts Membership?
Your membership is based on the patient. If you are a family member, please check the box for the patient (MH is or adults, MLH is for children with heart defects)
Membership Type
Name (Mr/Mrs/Ms) *
full name
Your answer
Street Address
Your answer
Your answer
Your answer
Your answer
email address *
Your answer
Your answer
preferred contact
May Mended Hearts staff or volunteers contact you regarding local chapter opportunities?
(optional for Mended Hearts reporting purposes in aggregate only). Also, if you wish to receive support we will utilize this information to properly match you up with a peer mentor.
Your relationship to heart patient
Name of heart patient
Your answer
Date of birth
Optional except for Mended Little Hearts patients
Your answer
Date of surgery/procedure
Your answer
Type of surgery/procedure
please choose from list below - check all that apply
Name of Primary Caregiver/Family Member
Your answer
Caregiver email
Your answer
Your answer
Many chapter newsletters include surgery/procedure anniversaries of members.
Please indicate here if you are agreeable to having your name published in this way
Add my email to monthly national email updates?
Parent Matching Program (optional for Mended Little Hearts families)
Parents finding out about their child's heart defect often feel lost and alone—like no one truly understands what they are going through. With Mended Little Hearts Parent Matching, you will be connected to other parents who have a child with a heart defect and can relate to the feelings "heart parents" experience and questions they may have. We can match you by your child’s diagnosis, your geographic area, or both. You can choose to receive emails or a telephone call — whichever works best for you.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms