Membership Application Form

2021-2022 Membership Application

Eganville and District Seniors
Membership is free. A donation would be kindly appreciated to offset the costs assocaited with our programs.
The Eganville & District Seniors is committed to the protection of all personal information collected. A copy of our privacy policy can be requested from the office. Personal information contained in this file is confidential and will not be shared with other organizations. It will be used to maintain a record of the members of our organization and to inform members about upcoming events, activities and fundraising efforts. It will only be shared in compliance with the Ontario Corporations Act.
I hereby apply for a membership in the Eganville & District Seniors Citizens' Needs Association which runs a fiscal year from April 1st to March 31st.
Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail
example@example.com
Municipality *
Distance from Centre *
In KM
Date of Birth *

Month Day Year
Gender *

Male Female Other
Marital Status *
Are you a Veteran? *

Yes No
Are you bilingual? *

Yes No
Do you usually spend part of the year (e.g., a month or more) away from home? *

Yes No
How do you usually get around? Please specify: *

Walking Driving myself Volunteer drivers Family members Other
Do you have any allergies we should know about? Please specify: *
Do you have any health concerns we should know about? Please specify: *
In case of injury or accident, who should we call? Please provide a name and phone number: *
This membership is a: *

Renewal New Membership
I give the Eganville & District Seniors permission to have my picture taken for possible use in promotional material: *

Yes No
Would you like us to call or email you with information about our services and activities?

Yes No Call Email
Check the activities/ services that you might be interested to participate in: *

Art Bridge Computer Club/Class Diabetic Support Diners' Club/ Drive Thru Dinner Euchre Exercise Classes Frozen Meals Home Maintenance Meals on Wheels Memory Cafe Reiki Tai Chi Telephone Assurance Transportation Yoga Zumba Other
Check the volunteer positions you might be interested in: *

Board of Directors Committee Member Diners' Club Fundraising Meals on Wheels Marketing/ PR Office Receptionist Program Volunteer Telephone assurance Volunteer Driver Income Tax Other
Interested in sharing your skillsets? What is your background & interests you would be willing to help with?
We welocme all constructive feedback. We know that we can always improve our services. Please feel free to talk to any of our staff members.

I have read the code of Conduct and Responsibilty of Membership and agree to abide by these standards of behaviour.
Comments
Signature *

Clear
Signature Date *

Month Day Year
Date
Should be Empty:

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2021-2022 Membership Application