Membership Application Form
For new members or to update information on file. Membership is from January - December. Membership is open to anyone 18+ or older. Benefits: newsletter mailed to your home every month and 10% discount at the Senior Center Thrift Store. PLEASE PRINT OFF FORM OR BRING TO CENTER TO PAY YOUR MEMBERSHIP FEE. Thanks!
Your Name
*
First Name
Last Name
Your Birthday
*
-
Month
-
Day
Year
Date
Email
example@example.com
Spouse's Name (enter only if applying as a Couple's Membership)
First Name
Last Name
Spouse's Birthday
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Membership Type: (you'll need to pay your membership fee at the Senior Center or mail in payment to: 608 E. 3rd Ave, Moses Lake, WA 98837)
*
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Individual Membership
$40.00
$
40.00
Couple's Membership
$60.00
$
60.00
Submit
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