Wayne Adult Community Center
1502 Hamburg Turnpike (Schuyler Colfax Campus)
Wayne, NJ 07470

Membership Application

Mr.
Mrs.
Ms.


First name


Last name

Street address (include apartment number if any)
, NJ
City

Zip Code
Not a valid NJ zipcode.
Phone

Area Code

Exchange

Number

Extension as
dialed (if any)

Invalid telephone number - See red entries

         
Email address (optional)
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First Name Last Name

Street City Zip
Telephone Email



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


Please indicate activities of greatest interest to you
Bridge(Contract and Duplicate)
Computer Fun Meetings
Lending Library
Painting Group
Pizza and other Parties
    Canasta
Dances (Big Band)
Mah Jongg
Pinochle
Tennis
    Computer Classes*
  *Available to people of any age.

Discussion Group
Special Events (e.g. Art shows, Trips)
Other Activities

      How did you hear about us?

Dues: $25 for a one-year membership or renewal, $40 for two years





    Office use:     MP 7__________     Acctg. __________     File __________
Wayne Adult Community Center

Emergency Contact information

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   
Member's address   
Member's telephone   
   
Preferred Hospital
   
Name of Primary Contact
Relationship to you
Contact's home or work city
(please specify which one)
Phone number(s)
(please specify work, personal, etc.)
   
Name of Backup Contact
Relationship to you
Backup's home or work city
(please specify which one)
Phone number(s)
(please specify work, personal, etc.)

Please ensure that everything is filled in correctly,
then click the button to print the form.
Remember to sign it and bring or enclose your check,
made out to 'Wayne Adult Community Center'.
      

Form Updated October 27, 2016 - 2010