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Become a NSC Member

Welcome to the Northshore Senior Center Membership Form. Please fill out each line of the form and the user demographic form below. Your Information is kept confidential. After the submit button, you will be given the option to pay with credit card. If you'd like to pay by check, please make checks payable to: Northshore Senior Center and mail to: 10201 E. Riverside Drive • Bothell WA 98011.

Membership Plan

*Please be aware ALL memberships are non-refundable.

Home Branch/Program
Membership Option
NEW
RENEWAL
UPDATE INFO
PRIMARY MEMBER
Birthday
Month
Day
Year
Multi-line address

First & Last Name

By signing this document, I release Northshore Senior Center and all of its agents from any liability for any accident, injury, illness, or damages of any kind to persons or property that might occur while as a result in attending the Northshore Senior Center and/or participating in their activities. I also authorize any pictures, videos or recordings taken of me while I am participating in NSC activities to be used in Northshore Senior Center publications. (The staff will make every effort to notify you prior to using your photograph).

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Date
Month
Day
Year

--------- MEMBER / USER / PARTICIPANT DEMOGRAPHIC FORM ---------

THIS INFORMATION IS CONFIDENTIAL. It is important in seeking and receiving GRANT FUNDING and for PLANNING PROGRAMS. Thank you for taking the time to complete the voluntary survey.

Gender Identity
Man
Woman
Non-Binary
Prefer to Self Identify
Prefer not to answer
Other
Marital Status
Married
Divorced
Single
Widowed
Partnership
Do you identify as a member of the LGBTQIA+ community?
No
Yes
Prefer not to answer
Do you have a disability?
Yes
No
Prefer not to answer
Are you homeless or living in a temporary shelter?
Yes
No
Prefer not to answer
Are you limited in the English language?
Yes
No
Other
Are you a refugee or immigrant?
Yes
No
Prefer not to answer
What is your racial identity? (Check all that apply)
What is your ethnicity?
Military Service
Yes
No
Prefer not to answer
Military Family Status
Household Income
One Person Household
Two Person Household
Are you interested in volunteering?
Yes
No
How did you hear about NSC?
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