Northshore Senior Center Membership

(membership is for twelve months)

New Membership or Renewal?: If Renewal, New Address?:

PRIMARY MEMBER information (Please fill in ALL information)

Middle Initial:
Nickname: Gender:  

County:


Preferred Phone:

PRIMARY MEMBER'S Emergency Contact Information

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Contact's Home Phone: Emergency Contact's Work Phone:
2nd Emergency Contact Name:

2nd Emergency Contact Relationship:

2nd Emergency Contact's Home Phone: 2nd Emergency Contact's Work Phone:
Primary Member Doctor's Name: Doctor's Phone:

NOTE: If COUPLE MEMBERSHIP, only ONE newsletter will be mailed out. It will go to PRIMARY MEMBER address.


ADDITIONAL MEMBER information for COUPLE membership

Relationship to Primary Member:

First Name: Last Name: Middle Initial:
Nickname: Gender:  
Street Address:

County:

City: State: Zip Code:
Home Phone: Mobile Phone: Preferred Phone:
Email:

ADDITIONAL MEMBER'S Emergency Contact Information

Emergency Contact's Name: Emergency Contact Relationship:
Emergency Contact's Home Phone: Emergency Contact's Work Phone:
2nd Emergency Contact Name:

2nd Emergency Contact Relationship:

2nd Emergency Contact's Home Phone: 2nd Emergency Contact's Work Phone:
Doctor's Name: Doctor's Phone:

Yearly Household Income

This information is optional and is needed for some of our funders; it will not be shared and will be kept confidential.

Income:

ABOUT PRIMARY MEMBER

Birth Month: Birth Year:
Veteran: Spouse of Veteran:
Ethnicity:
Current Volunteer?:
Interested in Volunteering:

ABOUT ADDITIONAL MEMBER of COUPLE MEMBERSHIP

Birth Month: Birth Year:
Veteran: Spouse of Veteran:
Ethnicity:
Current Volunteer?:
Interested in Volunteering:

Which Center will you be attending?

Centers attending:

Authorization

PRIMARY MEMBER

Picture Authorization:

Yes, I hereby authorize any pictures taken of me while I am participating in Senior Center activities to be used in Northshore Senior Center publications. (The staff will make every effort to notify you prior to using your photograph)

ADDITIONAL MEMBER of COUPLE MEMBERSHIP

Picture Authorization:

Yes, I hereby authorize any pictures taken of me while I am participating in Senior Center activities to be used in Northshore Senior Center publications. (The staff will make every effort to notify you prior to using your photograph)

Liability Release:

Yes, I release Northshore Senior Center and all of its agents from any liability for any accident, injury or damages of any kind to persons or property that might occur while participating in Northshore Senior Center activities

Liability Release:

Yes, I release Northshore Senior Center and all of its agents from any liability for any accident, injury or damages of any kind to persons or property that might occur while participating in Northshore Senior Center activities



After you click submit, you will be returned to the "membership page"

You will need to scroll up and click on the link to the membership payment