MEMBERSHIP REGISTRATION

Want to become a member of the Highland Senior Activity Center?

Please answer ALL of the questions below to register to become a member. All answers will be kept STRICTLY CONFIDENTIAL.

CONTACT INFO

Name:
Name You Go By (if different than above):
Street Address:
City:
County:
State:
Zip Code:
Home Phone:
Cell Phone:
Email Address:
May we send you center-related emails such as registration date reminders?
 Yes    No
Are you interested in volunteering at the center?
 Yes    No

PERSONAL INFO

D.O.B.:
Gender:
 Male    Female
Disabled?
 Yes    No
Do you consider yourself disabled?
 Yes    No
US Military Vet?
 Yes    No
Registered Voter?
 Yes    No
Marital Status:
 Married    Single
Living Arrangements:
 Live Alone
 Live with Spouse/Adult Relative
 Live with Caregiver
 Other
Do you rent or own your home:
 Rent    Own  Other
How many persons live in your household:

EMERGENCY CONTACT INFO

Primary Contact Name:
Relationship:
Address:
City:
State:
Zip Code:
Telephone:
Alternate Phone Number:
Secondary Contact Name:
Relationship:
Address:
City:
State:
Zip Code:
Telephone:
Alternate Phone Number:
Comments:
 We respect your privacy. All information will be kept strictly confidential.

This field is present to prevent automated submission systems. If you see it, please do not fill in a value.



Request Information


Name:
Phone:
Email:
Preferred Contact Method:
 Email      Phone
How can we help you?
 We respect your privacy. We will not share your email address.

This field is present to prevent automated submission systems. If you see it, please do not fill in a value.

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