Membership

Membership Category *

New Membership
Renewal Membership

Membership fee is $30 annually.

Membership Information

Name *

First

Last

Date of Birth *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Are you signing up for a Single Membership or Joint Membership?

Single Membership - $ 30.00
Joint Membership - $ 60.00

Spouses Name *

First

Last

Spouses Date of Birth *

Spouses Phone *

Spouses Email *

Spouses Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Information

Name of Contact *

First

Last

Relationship *

Primary Phone *

Work Phone

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Are you interested in becoming actively involved?

Please check one below *

Yes, I would like to become actively involved, and have time to devote.
Yes, I would like to become actively involved, but have limited time to devote.
No, I do not wish to be actively involved, but do wish to take full advantage of MSCC membership benefits.

Activity and Volunteer Interests

Activities I would be interested in:

Card Games
Pool/Billiards
Crafting
Exercise
Wii Bowling
Line Dancing
Art Class
Cooking
Shuffleboard
Other

Areas where you would like to volunteer: *

Happy Paks & Weekly Dinners
Thrift Room
Craft Fairs/ Rummage Sales
Events & Activities
Library
Other
None

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Applicant Signature

Date Signed

WAIVER OF LIABILITY (please check the box to agree to the following terms and conditions)

I understand that all programs/activities involve some risk of accident or injury. I agree to indemnify the Minneluzahan Senior Citizens Center and hold them harmless from any liability, claims, demands, and judgments arising at any time when I participate in any program or activity. Therefore, my choice to participate at the “Minneluzahan Center”, including the use of its equipment, is at my own risk. *

I Agree

I authorize the Minneluzahan Center Staff and Board Members to act in my behalf to authorize medical treatment to, upon, or for, the benefit of myself for any injury or illness which may occur from my participation. I recognize that such treatment shall be my full responsibility. In the event of a more serious injury or illness, requiring emergency medical treatment, I authorize such personnel to see that I am transported for treatment at the nearest medical facility, with the related expense being my full responsibility. *

I Agree

I also here by grant permission to the Minneluzahan Center to use for any official purpose any photographs, videotapes, recordings, or any other records of program activities depicting myself. *

I Agree

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Signature

I have carefully read, understand, and agree to the policies as stated above.

Date

Payment

Thank you for joining the Minneluzahaun Senior Center!

Total

$ 0.00

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Membership Information

Emergency Contact Information

Are you interested in becoming actively involved?

Activity and Volunteer Interests

WAIVER OF LIABILITY (please check the box to agree to the following terms and conditions)

Payment

Terms & Conditions

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