Activity Center Membership Application

Senior Activity Center

Membership Application
Date

MonthDayYear
Date
Welcome to CHEER

Hello and warmest welcome from all of us at CHEER! We are thrilled to have you join our community-focused organization, committed to enriching the lives of mature residents in Sussex County.

What CHEER Offers:
- Diverse Programs & Services: Our aim is to offer fulfilling experiences. As a CHEER member, you'll have access to a variety of programs and services tailored to diverse interests and needs.
- Local Activity Centers: Located across Sussex County, our centers offer freshly prepared meals and a host of activities ranging from crafts and games to health and fitness programs. We also host educational sessions, entertainment, and local travel opportunities.
- Fun and Community: At CHEER, fun is central to what we do. Whether you're joining us in-person at our facilities or enjoying our outdoor events, there's something for everyone.
Your Membership Benefits:
- Your annual membership fee of just $30 unlocks all these opportunities, fitness center access and more, enriching your life with more joy and community connection.
We're excited to welcome you to the CHEER family and look forward to making a positive difference together.

Warm regards,

Beckett Wheatley, CEO, CHEER, Inc.

Health Information
Client Name: {name}

Home Phone: {homePhone}

Date: {date}
Primary Care Physician*

First NameLast Name
Primary Care Physician Phone*
Please enter a valid phone number.
Do you have a second Primary Care Physician you would like to list?

YesNo
Primary Care Physician 2

First NameLast Name
Primary Care Physician 2 Phone Number
Please enter a valid phone number.
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship?*
Do you have a second Emergency Contact you would like to list?

YesNo
Emer. Contact 2 Name

First NameLast Name
Emer. Contact 2 Phone Number
Please enter a valid phone number.
Emer. Contact 2 Relationship
Please list any medical conditions or diagnosis (Please describe)
Do you have any allergies?*

YesNo
Please list any allergies, severity, and what to do if you have an allergic reaction.
Please list all medications you take, dosage, and frequency.

Terms and Conditions
Release and waiver of liability
In consideration for being permitted to participate in CHEER Programs, Activities and Events, I, {name} hereby agree to release and forever discharge CHEER, Inc., its directors, officers, employees, agents, and assigns, from any and all claims, demands, actions, causes of action or suits of any kind or nature whatsoever, which have resulted or may develop in the future as a result of any Program, Activity or Event conducted or sponsored by CHEER, Inc.

I further declare that the terms of this waiver have been completely read, are fully understood and voluntarily accepted for the purpose of making full and final settlement of any and all damages above mentioned, and for the express purposes of precluding forever any further or additional claims arising out of any possible action involving the undersigned.

I further agree and authorize CHEER and its agents to utilize any photos or images taken of me while on CHEER property or participating in any CHEER-sponsored program, activity or event for the purposes of marketing or promotional activities.

This release is binding on my heirs, executors, assigns and administrators. This is a voluntary release for any and all future possible causes of action.

By my signature below, I acknowledge that I have read and understood all of the above.
Signature*

Clear
Date

MonthDayYear
Date

Have you ever been a member of CHEER before?

YesNo
When were you last a member of CHEER?
Date or Year (best guess is fine)

Membership

CHEER MembershipA one year membership that provides access to all CHEER centers. (Membership expires Jan. 1, 2026)

$30.00 Quantity

Total

$0.00

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

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