Services > Just for Seniors > Application Form
Application form

Yes! I want to become a Just for Seniors member

I understand that the membership program is not an HMO or a Medicare supplemental insurance product. Medicare is not a requirement for this free program. Adequate hospital coverage is my responsibility.

Primary member name:________________________________________________

Gender: ___ Male ___ Female

Birthdate:_______/______/_______

Home Address:_____________________________________________________

City:________________________State:________________Zip:______________

Day phone: (_____) ______-__________

Spouse:___________________________________________________________

Spouse's birthdate:_______/_______/_______

Send us your application! Print out this form and mail to:

Just for Seniors
LLUMC East Campus
25333 Barton Road
Loma Linda, CA 92354

Questions? Email justforseniors@ahs.llumc.edu.