| First Name | Last Name |
| Street | City | Zip |
| Telephone |
By my signature, I certify that I am at least 55 years of age.
___________________________________________
Annual dues $25/$40* paid by: Check #_____ Check Date ____________ Cash $________
* $40 provides a two-year membership or renewal
Other Activities
How did you hear about us?
If you suffer a major health problem or an accident while at our center, we will need the information below
in order to contact a family member, a friend, or a neighbor, to advise them of your situation.
Please fill in the name and other necessary information about the person you would like us to call.
If possible, also specify a backup person to call if the primary contact is not available.
| Member's Name | This is copied automatically from its earlier entry | |
| Member's address | This is copied automatically from its earlier entry | |
| Member's telephone | This is copied automatically from its earlier entry | |
| Preferred Hospital | ||
| Name of Primary Contact | ||
| Relationship to you | ||
| Contact's home or work city (please specify which one) |
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| Phone number(s) (please specify work, personal, etc.) |
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| Name of Backup Contact | ||
| Relationship to you | ||
| Backup's home or work city (please specify which one) |
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| Phone number(s) (please specify work, personal, etc.) |