Silverton 50+ Center New Member

Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How Did You Hear About Us?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If enrolling another person, e.g., spouse, please complete below.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In case of emergency, please contact:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship
City
Participant Liability Waiver and Hold Harmless Agreement

Please read this form carefully and be aware that by registering for and/or participating in programs sponsored by the Silverton Senior Center, you will be waiving your rights to all claims for injuries you might sustain arising out of participation and you will be required to indemnify, hold harmless and defend the Silverton Senior Center for any claims arising out of participation in Senior Center activities.
By adding your name here, you agree to the terms and conditions listed above.
First Applicant

First NameLast Name
Second Applicant (if applicable)

First NameLast Name
MonthDayYear
2 digit month, 2 digit day, 4 digit year
For Office Use Only

date entered in MSC

Total received:

Payment method (Cash, Check #, Debit/Credit):

Received by:
Should be Empty:

For Office Use Only