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LEW MARTIN SENIOR CENTER MEMBERSHIP APPLICATION

FIRST & LAST NAME:
CURRENT ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE NUMBER:
BIRTHDAY (DAY/MONTH):
ANNIVERSARY (DAY/MONTH):

EMERGENCY CONTACT

FIRST & LAST NAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
RELATIONSHIP TO YOU:
PHONE NUMBER:

SPOUSE INFORMATION IF JOINT MEMBERSHIP

FIRST & LAST NAME:
DATE OF BIRTH (DAY/MONTH):

SIGNATURES

I AUTHORIZE THE SENIOR CENTER TO USE MY EMAIL ADDRESS FOR EMAILING NEWSLETTERS. I UNDERSTAND THE SENIOR CENTER WILL NOT SELL OR USE MY INFORMATION. I AGREE TO LET THE SENIOR CENTER USE ANY PHOTOS OF ME FOR MARKETING PURPOSES.

I DO NOT WANT MY PHOTO USED

SIGNATURE OF APPLICANT:
 
DATE (DD/MM/YY):
SIGNATURE OF SPOUSE (ONLY IF FILING FOR JOINT MEMBERSHIP)
 
DATE (DD/MM/YY):