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Online Membership Registration

Membership is valid for 12 consecutive months, e.g. if you join in May 2010, your membership will be valid through April 2011.
Members receive a 50% discount on class fees and most activities.
Reduced fees and scholarships for membership are available for anyone who cannot afford membership fees. If you need
this option, please download the membership form, fill it out, and mail or bring it to the center.

If you wish to use a credit card, but are having trouble navigating through this form, please contact contact the Membership Coordinator, Patricia Gustafson, at 425-286-1072 or patriciag@seniorservices.org to meet at the center to help you with the form.

What Center(s) will you be attending:

BothellMill CreekWoodinvilleKenmoreAdult Day Health

What type of membership would you like to purchase:

Individual $30
Couple $50
Gift membership – Consider buying a gift for a friend!

First Name:

Last Name:

Gender:

MaleFemale

Street:

City:

State:

Postal Code:

County:

Telephone:

Email Address:

Please enter your year of birth:

Are you Under 55:

Are you a veteran:

Yes
No

Are you the spouse/partner of a veteran:

Yes
No

Race/Ethnicity:

Spouse/Partner's Information

First Name:

Last Name:

Gender:

MaleFemale

My Partner/Spouse's address is different than mine.:

Telephone:

Email Address:

Please enter your spouse/partner's year of birth:

Under 55:

Is your spouse/partner a veteran:

Yes
No

Is your spouse/partner the spouse/partner of a veteran:

Yes
No

Race/Ethnicity:

This information is optional. Please note this information is needed to qualify for certain grants and will NOT be shared.

Single Household Income:

Two Person Household Income:

Please don’t mail me the quarterly Newsletter, I will read it online. (Save the Senior Center money and save a tree too!):

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).

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.

One of the NSC’s Strategic Framework goals is to “contribute to and engage with the community, using the skills and strengths of seniors.” You are a vital resource, having untapped skills and expertise. Members and Volunteers fill important positions, leading classes and activities, and sharing their experience when they find the opportunities. Please share your knowledge and expertise by answering the questions below. This information will be treated confidentially. Thank you!

Are you a new member:

Yes
No

Profession:

Retired:

Yes
No

Working full time:

Yes
No

Working Part Time:

Yes
No

Are you a current Northshore Senior Center volunteer:

Yes
No

If no, are you interested in volunteering:

Yes
No

Previous Volunteer Experience:

Your Work Experience/ Skills:

Carpentry/ Handyman
Spread Sheets
Graphics
Word Processing
Sales
Marketing
Bookkeeping
Foreign Language
Admin
Receptionist
Budgeting
Supervision
Filing
Finance
Legal
Photography
Other

Your Volunteer Areas Of Interest:

Auction
Kitchen
Rummage Sale
Reception
Coffee Bar/ Cafe
Garden/Landscaping
Software Instructor
Gift Shop
Library
Fitness Center
Database Input
Admin
Other

Your Spouse/Partner's Volunteer Information

Is your spouse/partner a new member:

Yes
No

Profession:

Retired:

Yes
No

Working full time:

Yes
No

Working Part Time:

Yes
No

Is your spouse/partner a current Northshore Senior Center volunteer:

Yes
No

If no, is your spouse/partner interested in volunteering:

Yes
No

Previous Volunteer Experience:

Your Spouse/Partner's Work Experience/ Skills:

Carpentry/ Handyman
Spread Sheets
Graphics
Word Processing
Sales
Marketing
Bookkeeping
Foreign Launguage
Admin
Receptionist
Budgeting
Supervision
Filing
Finance
Legal
Photography
Other

Your Spouse/Partner's Volunteer Areas Of Interest:

Auction
Kitchen
Rummage Sale
Reception
Coffee Bar/ Cafe
Garden/Landscaping
Software Instructor
Gift Shop
Library
Fitness Center
Database Input
Admin. Office
Other

Emergency Contact Information

Emergency Contact:

Relationship:

Home Phone:

Work Phone:

Doctor's Name:

Doctor's Phone Number:

Spouse/Partner Emergency Contact Information

Emergency Contact:

Relationship:

Home Phone:

Work Phone:

Doctor's Name:

Doctor's Phone Number:

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