Charlestown Senior Citizen, Inc

Membership Form

MEMBERSHIP FORM

Name _____________________________________________________________

Address ___________________________________________________________

City __________________________ State__________ Zip __________________

Telephone _____________________ Email ______________________________

Date of Birth _________________Month _________________Day  (No Year required)

Membership Fee:   $1.00 a year or $10.00 Lifetime Membership Fee

_________ Payment attached  

                             (Please make checks payable to Charlestown Senior Citizen, Inc.)

_________ I’ll bring it next visit

_________ Please cover my Membership from the Membership fund.

                             (We do not want finances to keep you from coming to the Senior Citizen group.

                                If you need help with the Membership fee, all you have to do is check this line,

                                and the fee will be paid from our Membership fund.)

INFORMATION:

How did you hear about Charlestown Senior Citizen, Inc?

What program or activity would you like to see offered?