Eldercare - Membership Form

Membership Application

The CENTER for SENIORS is a place where adults can gather for activities, learning experiences, and fellowship. The CENTER is managed by Eldercare Systems, Inc. and is not affiliated with any organization, church or religious group. It receives no county, state or federal funding. The CENTER operates solely on its membership fees and the generosity of Eldercare Systems, Inc. The goal of the CENTER for SENIORS and its programs is to provide a safe, fun place for older people to meet and take an active role in staying healthy, active and mentally alert. Membership is restricted to adults over the age of 50 who are able to participate in CENTER activities without assistance. A caregiver may accompany members who require assistance.

I desire membership in the CENTER for SENIORS. I agree to abide by all rules, regulations and hours set forth by the CENTER and its management. I will respect fellow members and the property of the CENTER. I understand that the CENTER for SENIORS is a social place; it is not a medical facility and it is not staffed to provide medical care. Although activities and programs at the center are designed to help me remain healthy, active and independent, membership in the CENTER for SENIORS does not guarantee my safety or continued good health. I further understand that the CENTER for SENIORS, their employees, volunteers, shareholders, officers, directors, agents (collectively Eldercare Systems, Inc.) are not liable for any negligent or willful act nor unanticipated event which might result in injury, illness, emotional trauma or death while participating in any program, service, event or function held at, or organized under the auspices CENTER for SENIORS. Neither is the CENTER for SENIORS nor Eldercare Systems, Inc. responsible for the loss or damage to any personal property, which I may bring to or leave at the CENTER. I hereby release and forever discharge Eldercare Systems, Inc. from and against all liability arising from my membership and participation in the CENTER for SENIORS.

First Name
Middle Initial
Last Name
Street Address
City
State
Zip
Phone Number
Email Address
Marital Status
Birthday (year optional)
Please indicate areas of interests	Arts & crafts Board games Card playing Diet/Exercise Events(Cooking-Offs, Dancing, Story Telling, Gong Shows, Dances, Parties, etc.) Art Gallery Internet/Computer Access Movies (old / current) Pot luck Luncheons (noon) Pot luck Dinners (5pm) Singles Group/Activities Trips/Travel Seminars/Classes: (Bible Study Art, Health, Legal, Scrap Booking, Dancing, Bridge, Cooking, Investment, etc.) Other
I would like to have the following things provided/available at the Center:
I prefer (check all that apply):	daytime meetings/activities evening meetings/activities weekend meetings/activities
I would like to volunteer at the center and have interest or talents in the following areas:	Board Member Club Officer Memberships Reception/Hostess Driver/Transportation Maintenance/Handyman Food Preparation Cleaning Visit Shut-In Members Curriculum/Events Phone Calls Promotion Speaker/ Entertainer/ Instructor/ Trainer
Membership *Membership fees are non-refundable	Annual Membership - $100/year Membership in the 50 & Better Center for Seniors is for the calendar year, from January through December Quarterly Membership - $35/quarterly Members may choose to pay their memberships in four equal installments ($10/month + $5 administrative fee) Lifetime Membership - $2500 Lifetime Members support the goals of the center and contribute towards its future success.
Emergency Contact/relationship
Emergency Contact Telephone