Membership Form

Section 1: Basic Information

Full Name:   First Name*   Last Name*
Email Address:   Email*
Phone Number:   Area Code*   Phone Number*
Age:   Number*
Address (City, State, ZIP):   Street Address*   Address Line 2*   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)
Housing & Senior Living Options (Independent, Assisted, or Memory Care)   Home Care or Personal Assistance   Transportation Services
Health Insurance / Medicare Support   Physical Therapy or Mobility Services   Technology Help or Device Training    Legal or Financial Services (Estate Planning, Benefits Help, etc.)   Wellness & Fitness Programs   Medical Equipment or Supplies   Travel & Leisure for Seniors   Nutrition & Meal Services   Other (please specify): *
  If other, please specify:

My Subscriptions*

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

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

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

Please verify that you are human*

Signature*

Membership Registration Form