Masonic Widows New Member Form

ST. ALBAN LODGE NO. 529

FREE & ACCEPTED MASONS OF PENNSYLVANIA

Masonic Blood Drive and Organ Donor Information

MASONIC WIDOWS NEW MEMBER FORM

NO BLOOD DONATION REQUIRED

Membership is Free

New member number: _______________________ (to be assigned by blood club)

(Please print the following information legibly and complete the entire form

First Name: _________________________ M. I.:_______ Last Name: ____________

Date of Birth:___________ Telephone #: __________________ Blood Type: _______

Apt. Name: ____________________________________ Apt #: ___________________

P. O. Box: _______________ R.D. #: ______________ Box #: ______________

Street Address: __________________________________________________________

City: _________________________ State: ____________ Zip Code: _________-____

Husband’s Full Name: ___________________________________________________

Husband’s Lodge Name: ________________________Lodge#: ______ District: ____

Mail to:

Masonic Blood Donor Club

C/O Masonic Temple

One North Broad Street

Philadelphia, PA 19107

(Photocopy this form as needed)

MASONIC BLOOD DONOR CLUB OF PENNSYLVANIA

COVERAGE

● The Member, his spouse and all children up to 18 years of age.

● No limitation on number of units of blood.

● No geographic limitations

REQUIREMENTS FOR MEMBERSHIP

● Open to all Pennsylvania Freemasons.

● Also open to Members of Pennsylvania Women’s groups having Masonic affiliation as a requirement from membership.

● Requirement of One donated unit of blood by the applicant or by a substitute.

● There is no monetary obligation for membership.

● Widows of all Pennsylvania Freemasons are automatically covered, upon application, without the required one unit of blood.

HOW TO REACT WHEN BLOOD IS NEEDED

● Inform the hospital that the patient is a member of the Masonic Blood Club of Pennsylvania. This is all that is normally needed.

● If the hospital bills the patient for blood, DO NOT PAY FOR THE UNITS. The patient is responsible for the administration of the blood but not the blood itself. The administrative costs are normally covered by insurance.

● Contact the Secretary of the Blood Club (his address is on the Membership Card), giving him the date of the procedure, the name of the patient and place where the procedure was done, plus any other pertinent information.

● The Secretary will arrange to have the required units of blood replaced.

● If another bill is received showing the same charges, they can be ignored. This is because there may be an overlap in billing cycles. If more bills are received, call the Secretary for follow-up.

Secretary: Chairman:

LeRoy O. McClellan F. Rick Knepper

(856) 786-4098 (717) 263-1189

http://www.bloodsaves.com/