Top Left Corner Top Right Corner
Yuma Regional Medical Center
Pad Lock
Before TopNav
Left Side

Left Nav Bottom

Decrease (-) Restore Default Increase (+) font size

Email Forms Manager

Year Around Membership Application

By filling out the following membership application, you and your spouse are becoming members of Yuma Regional Medical Center’s FREE membership program called Silver Connections. Silver Connections is a free comprehensive program of health-related services including activities, educational programs, a newsletter, and discounts for people age 55 and older.

Only one form necessary per couple.

* Indicates required information
Date: *  Calendar (mm/dd/yyyy)
First Name: * 
Last Name: * 
Spouse First Name: 
Spouses Last Name: 
Date of Birth: *  Calendar (mm/dd/yyyy)
Spouse's Date of Birth:  Calendar (mm/dd/yyyy)
Email Address: 
Phone Number: 
Address: * 
City * 
State * 
Zip * 
Country * 
Who is your Primary Insurance Provider? 
Who is your Secondary Insurance Provider? 
Would you like to be contacted by a member of our Silver Connections Team if you are hospitalized: * 
How did you hear about Silver Care * 
What health topics and issues you would like to learn more about? 

If Other, please specify:

Authentication * 

If the challenge words are too difficult to read, click here to refresh.

Yuma Regional Medical Center will not share or sell this information to any third parties.

Related Links

Right Side
Footer Left Footer Tile Footer Right
© 2016   Yuma Regional Medical Center  |  2400 S. Avenue A  |  Yuma, AZ 85364  |  928-344-2000