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MEMBERSHIP |
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I accept responsibility for my own medical coverage. I, hereby, give permission for the staff and volunteers with the Square One Older Adult Centre, to arrange for any emergency medical care, including hospitalization and transportation if necessary, and agree to pay for all expenses and costs incurred thereby. If emergency medical care is required, all attempts will be made to contact emergency contact person(s) shown above. I agree to release and indemnify and save harmless the City of Mississauga, Square One Shopping Centre, OMERS Realty Management Corp, and the staff and volunteers of the Square One Older Adult Centre from all claims arising from participation in any program, activity, event, or trip organized by the staff and/or volunteers at Square One Older Adult Centre by any cause whatsoever.
Signature: Date: (month/day/year)
NOTE: Please inform the Centre of any changes to address or phone numbers. Annual Membership for 2008 $24.00 (Residents of Mississauga) Amount paid $ $28.00 (Non-Residents) Annual Partnership Fee for 2008 $12.00 (Residents and Non-Residents) □ Silayan □ Iranian □ Caribbean □ Chinese
NOTE: There is a minimum fee of $1.50 each time a member attends a program activity. Please return this form with cash or cheque payable to Square One Older Adult Centre. In person to: Square One Older Adult Centre Administration Office on drop-in days. By mail to: Square One Older Adult Centre, 100 City Centre Drive, P.O. Box 2214, Mississauga ON L5B 2C9 |
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Square One Older Adult Centre |