2024 Membership Application

Dexter Senior Center 2024 Membership Application

Complete the form below to sign up for our membership.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
E-mail
Phone Number:*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Township

City of DexterDexter TownshipScio TownshipWebster TownshipOther
I would like to receive my newsletter via...*

Picking Up at the CenterEmailOther
I would like to receive your Membership Discount card via...

Mail my card to meI'd like to pick my card up
Where did you hear about us?

A Current MemberA FriendFacebookWebsiteNews ArticleLocal BusinessOther
Are you or your spouse a Veteran?
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Add Second Member from your Household
Name

First NameLast Name
Date of Birth

MonthDayYear
E-mail
example@example.com
Phone Number:

Area CodePhone Number
Agreements
Photo Rlease Agreement

I give permission to the Dexter Senior Center to use my photo for any promotion materials if taken while participating in any of the center's activities or events.
Waiver of Liability *

I understand that all programs/activities involve some risk of accident or injury. I agree to indemnify Dexter Senior Center and its affiliates and hold them harmless from any liability, claims, demands and judgments arising at any time when I participate in any program or activity. Therefore, my choice to participate at the Dexter Senior Center, including the use of its equipment, is at my own risk. I understand that Dexter Senoir Center does not provide insurance for participants, nor does it assume responsibility for accidents or injuries.
Emergency Release Waiver *

I authorize Dexter Senior Center personnel to act in my behalf to authorize medical treatment to, upon, or for, the benefit of myself for any injury which may occur from my participation. I recognize that such treatment shall be my full responsibility. In the event of a more serious injury that may require emergency medical treatment, I authorize such personnel to see that I am transported for treatment at the nearest medical facility, with the related expenses being my full responsibility.

Payment*

Membership for 55+You DO NOT need to be a resident of Dexter in order to join!

$25.00 Quantity

Membership for FuturesAnyone under the age of 55 is welcome to join as a "Future Member."

$40.00 Quantity

Donation - Many members give an additional donation at membership renewal, this greatly helps the senior center!

$20.00

Couples MembershipTwo 55+ in the same household

$50.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Dexter Senior Center 2024 Membership Application

Add Second Member from your Household

Agreements