Member Application

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
 

I would like to volunteer at:
Grannies' Attic
Celebrate Seniority office
Community Blood Pressure Screening / Helmet Fitter

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