MEMBERSHIP

MEMBERSHIP REGISTRATION FORM

 

Membership # __________

 

NAME: (Mr./Mrs./Ms.)                                                                   Male /Female (circle one)

 

ADDRESS:                                                                                      APT #                             

 

CITY:                                                                                  POSTAL CODE:                        

 

TELEPHONE:   (         )                                         BIRTH DATE:                                         

                                                                                                        (month/day/year)

E-MAIL ADDRESS:                                            

 

FAMILY DOCTOR:                                             DOCTOR’S PHONE:  (         )                

 

Are you a New Member?  □        or a Renewal Member?  □   (please check one)

 

Would you like to become a Volunteer?  Yes        No        

 

TWO PERSONS TO CONTACT IN AN EMERGENCY

 

NAME:                                                      NAME:                                                      ______

 

RELATIONSHIP:                                                 RELATIONSHIP:                                   

 

HOME PHONE (       )                                           HOME PHONE: (        )                           

 

BUSINESS PHONE (        )                                  BUSINESS PHONE (        )                    

 

Square One Older Adult Centre

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