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  • Membership Registration Form 

    Payment Form
  • Section 1: Basic Information

    Full Name:   *   *   
    Email Address:   *   
    Phone Number:   *   *   
    Age:   *   
    Address (City, State, ZIP):   *   *   *   *   *   



    Section 2: About You

    6. How did you hear about My Active Senior?   *   
    If other, please specify:      

    Which best describes you?   *   

    Which types of senior services are you most interested in learning about or may need in the future? (Select all that apply)
                
                            *  
      If other, please specify:                                                   

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      MyActiveSenior Member $50 + $1.75(processing fee)One-year Founding Membership. Includes access to all member benefits, discounts, and early event registration.(This membership helps fund our national senior event expansion and 2026 tour.)
      $51.75 for each year
        

      Credit Card
      Billing Address
    • Attestation
      By signing below, I agree for my credit/debit card to be debited in the amount of  $51.75

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