Alcohol and Drug Rehabilitation - Betty Ford Center Alumni Form

Alumni Feedback Survey

Alumni Change of Address Form to be used only by Alumni of the Betty Ford Center

	Check here if this is a change of an existing alumni address or e-mail information.
Title:	Not Specified Ms Mrs Mr Dr
First Name:
Last Name:
(please include last name at time of treatment if different now)
Address:
City:
State:
Zip:
Country:
E-Mail Address:
Date of Birth:
Home Number :
Cell Number :	(not required)
Work Number :	(not required)
Month/Year of Admission:	(not required)
Marital Status:
By clicking the "submit" button below, you give us permission to make the changes you requested to our alumni mailing list as indicated in the boxes you checked above. The information collected in this form is encrypted and sent to us through a secure server. We have taken all reasonable measures to protect the confidentiality of your information. However, no one can give absolute assurance that your information will remain secure, and normal risks exist that third parties may intrude on the server and view your information. By pressing the SUBMIT button you agree that you are aware of those risks and choose to send this information. If you do not wish to submit your information electronically, you may print this form and mail it to: Attn: Alumni Services P.O. Box 1560 Rancho Mirage, CA 92270 or fax it to: (760) 773-1849

Click on image to enlarge

May 2
Alumni Spring Event - BBQ

>> Alumni Events List

If any links are contained on this site, such links are intended for the convenience of visitors. The Betty Ford Center has no responsibility for or control over the content of any site to which any link applies. Links to any other sites shall not constitute sponsorship, approval or endorsement of such sites or any content therein.