Residents Rights and Future Medical Decisions Booklet Order Form "*" indicates required fields Facility Name:*Facility Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person:*Contact Phone Number:*Contact Email:* Booklets sold in bundles of 50. Member Pricing: $100/bundle + S&H | Non-Member Pricing: $150/bundle + S&HPricing:* Member Non-Member Residents Rights Booklet Bundle (50 booklets/bundle) Quantity* Price: $100.00 Quantity Future Medical Decisions Booklet Bundle (50 booklets/bundle): Quantity* Price: $100.00 Quantity Resident Rights Booklet Bundle (50 booklets/bundle) Quantity* Price: $150.00 Quantity Future Medical Decisions Booklet Bundle (50 booklets/bundle)): Quantity* Price: $150.00 Quantity Payment Information:How Would You Like to Pay?* Check Credit Card Tax (5.5%): $0.00 Service Charge: Price: $0.00 Shipping & Handling: Price: TOTAL AMOUNT DUE: Credit Card:*Card Details Cardholder Name Billing Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Back to WHCA/WiCAL Website
![WHCA/Wical Registrations [logo]](https://registration.whcawical.org/wp-content/themes/wihca-wical-pacdonation/images/logo.png){kind=logo}