MEMBER FORMNORTHSHORE SENIOR CENTER10201 East Riverside DriveBothell, WA 98011 www.northshoreseniorcenter.org(425) 487-2441Welcome 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(Required) $48 Single Membership $85 Couple/Dual Membership $500 Lifetime Individual Membership $750 Lifetime Couple Membership Please check if you would like to request a scholarship * Please be aware that ALL Membership fees are non-refundablePlease check Home Branch/Program(Required) Bothell Kenmore Mill Creek Transportation Health & Wellness Inclusion (additional forms required) Adult Day Health Other Today's Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PRIMARY USERMembership Option(Required) NEW RENEWAL NEW ADDRESS Primary User Name(Required) First M.I. Last Nickname/Salutation Date of Birth: Month/Day/Year(Required) Month Day Year Phone (H):(Required)Cell:(Required)Mailing Address (Including Apt#)(Required) Street Address 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 Email(Required) Emergency Contact Person:(Required) First Last Emergency Phone:(Required)Relationship to Member:(Required) Primary User - Signature(Required) Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920By 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).(Required) I Agree 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).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.PRIMARY USER1. Gender Male Female Other 2. Do you identify as a member of the LGBTQ community? No Yes, Lesbian, Gay, Bisexual, Questioning Yes, Other Yes, Other 3. Marital Status: Married Divorced Single Partnership Widowed 4. Do you have a disability? Yes No 5. Are you homeless or living in a temporary shelter? Yes No Prefer not to answer 6. Are you limited in the English language? Yes No If yes primary language is: 7. Are you a refugee or immigrant? Yes No Prefer not to answer 8. What is your race? (Check all that apply) American Indian or Alaska Native Asian or Asian American Black, African American, African Native American or Pacific Islander White/Caucasian Not Listed / Other Prefer Not To Say Unknown If Not Listed/Other, please add below: 9. What is your ethnicity? Hispanic/Latino Russian/Ukrainian South Asian Prefer Not To Say Other Unknown If Other, please add below: 10. Military Service Yes No Prefer Not to Say Unknown 11. Military Family Status Self Not Family Member Minor Dependent Spouse/Partner Surviving Spouse/Partner Other Dependent Adult 12. Are you interested in volunteering? Yes No SECONDARY USERMembership Option(Required) NEW RENEWAL NEW ADDRESS Secondary User Name(Required) First M.I. Last Nickname/Salutation Date of Birth: Month/Day/Year(Required) Month Day Year Phone (H):(Required)Cell:(Required)Mailing Address (Including Apt#)(Required) Street Address 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 Email(Required) Emergency Contact Person:(Required) First Last Emergency Phone:(Required)Relationship to Member:(Required) Secondary User - Signature(Required) Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920By 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).(Required) I Agree 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).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.SECONDARY USER1. Gender Male Female Other 2. Do you identify as a member of the LGBTQ community? No Yes, Lesbian, Gay, Bisexual, Questioning Yes, Other Yes, Other 3. Marital Status: Married Divorced Single Partnership Widowed 4. Do you have a disability? Yes No 5. Are you homeless or living in a temporary shelter? Yes No Prefer not to answer 6. Are you limited in the English language? Yes No If yes primary language is: 7. Are you a refugee or immigrant? Yes No Prefer not to answer 8. What is your race? (Check all that apply) American Indian or Alaska Native Asian or Asian American Black, African American, African Native American or Pacific Islander White/Caucasian Not Listed / Other Prefer Not To Say Unknown If Not Listed/Other, please add below: 9. What is your ethnicity? Hispanic/Latino Russian/Ukrainian South Asian Prefer Not To Say Other Unknown If Other, please add below: 10. Military Service Yes No Prefer Not to Say Unknown 11. Military Family Status Self Not Family Member Minor Dependent Spouse/Partner Surviving Spouse/Partner Other Dependent Adult 12. Are you interested in volunteering? Yes No HOUSEHOLD INCOME One Person Household Two Person Household ONE PERSON HOUSEHOLD $16,031 or less $16,032 - $26,723 $26,724 - $42,755 $42,756 or more TWO PERSON HOUSEHOLD $20,963 or less $20,964 - $34,943 $34,944 - $55,919 $55,920 or more CAPTCHA
