MultiCare Health System

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Ways to Help



Member Application


Each new member must fill out a separate form.

Name:     Date of Birth: 

Home Address:    

City:     State:    

Zip Code:

Phone:    Email:   

Marital Status:

  Single
  Married
  Widowed

Spouse's Name:


I am interested in attending a class on:
(check all that apply)

  Alzheimer's Disease & Resources
  Cholesterol
  Pain Management
  Diabetes
  Blood Pressure
  Nutrition/Diet
  Caregiver Support
  Other 

I would like a referral for: (check all that apply)

  Consulting Nurse
  Home Health/Hospice
  Medicare/Social Security
  Foot Care
  Local Food Banks
  Other 

Are you currently volunteering?

  Yes
  No

Do you want to learn more about community volunteer opportunities through Celebrate Seniority?


  Yes
  No


Your Interests (Check all that apply)

Health Prevention
  Volunteerism
  Day Trips
  Book Club
  Knitting/Quilting Group

Community Connections
  Free Movie Matinees
  Exercise Classes
  Walking Groups
  Health Talks/Potlucks

How did you learn about Celebrate Seniority?


  Peer
  Health Screening
  Internet
  Other