La Pine Senior Activity Center Membership Form

La Pine Senior Activity Center Membership Application

$40 Per Person Annually

* Special price now thru the end of March - $35.

May 1 - April 30th
Name: *

First Name Last Name
Today's Date: *

Month Day Year
Date
Date of Birth: *

Month Day Year
Date
Male or Female: *

Female Male
Home Phone *
Cell Phone
Email Address:
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
New Member or Renewal *

New Renewal
Spouse Name
Emergency Contact Name *
Phone Number of Emergency Contact *
Are you interested in Volunteering? We need help in the kitchen, food server, food delivery, event support, etc

Yes No
Once you click on SUBMIT it will take you to the next screen where you can choose to pay with PayPal or a credit card.
Note: some activities may be canceled or done differently due to COVID restrictions or Inclement weather.
For Office Use Only
Date Sent

Month Day Year
Date
Exp. Date

Month Day Year
Date
Date Entered in System

Month Day Year
Date
Entered By
La Pine Senior Citizens, Inc.
16450 Victory Way
PO Box 1279, La Pine, OR 97739
Phone: 541-536-6237
Fax: 541-536-1665
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