FAIRBORN SENIOR CENTER Membership Reg

FAIRBORN SENIOR CENTER
Annual Fee:

Individuals-$20.00

Married Couple-$35.00

Recreational Activities fee:

$1 per participation

Instructor and Materials fee:

Varies

If you are interested in becoming a member, please fill out the Membership application below. You must submit your membership fee before you become a member of the Senior Center. Please mail in, come in or call in to process your fees. For more information contact the Fairborn Senior Center (937) 878-4141.
MEMBERSHIP REGISTRATION

INDIVIDUAL
First Name
MI
Last Name
Date of Birth

Month Day Year
Date
Phone
Cell Phone
Would you like the Newsletter Emailed?

Yes No
Email
example@example.com
Current Address
City
State
ZIP Code
MEMBERSHIP REGISTRATION

Couple
Please fill this out for your partner. If you do not have a partner, please skip to Emergency Contact.
First Name
MI
Last Name
Date of birth

Month Day Year
Date
Is your Partner a member?

Yes No
If Yes, what is their membership number?
EMERGENCY CONTACT
Enter address and phone only if it is different from above!
Name
Relationship
Address

Address

Street Address Line 2

City State

ZIP Code
Phone
VOLUNTEER OPPORTUNITIES THAT MAY INTEREST YOU
Please select volunteer opportunities you maybe interested in:

Administrative Support Activities Leader Driver Social Services Board Member Committees Fundraisers Other
SIGNATURES
Signature of applicant

Clear
Date

Month Day Year
Date
Signature of spouse (only if for a joint membership)

Clear
Date

Month Day Year
Date
Should be Empty:

FAIRBORN SENIOR CENTER