2008

APPLICATION FOR MEMBERSHIP/TRAVEL INFORMATION

(Please Print Clearly One Form Per Applicant)

By Mail:  Send A Check or Money Order For $5 To: Saline Area Senior Center, 7190 N. Maple Rd., Saline MI 48176

Name_____________________________________________________________________________________________

Address___________________________________________________________________________________________

City, State, Zip ________________________________________________________Phone: ______________________

Township ________________________________________________Date of Birth______________________________

Male __________ Female __________                Previous Occupation_________________________________________

Hobbies __________________________________________________________________________________________

_________________________________________________________________________________________________

Would you like to volunteer for the center?  Yes/No  Area of Interest   ________________________________________

 

MEDICAL INFORMATION

***This Medical Information  Is Strictly Confidential.  It Is Essential That We Have This Completed

Form In Case Of Any Medical Emergency***

Medical Insurance Company(s) ________________________________________________________________________

In Case of an Emergency Contact:

1. Name________________________________________________________ Relation ______________________

                      Cell Phone # _________________________________ Home/Work #  ______________________________

2. Name _________________________________________________________ Relation _____________________

                       Cell Phone # ________________________________ Home/Work #  ______________________________

Doctor’s Name _______________________________________________________ Phone: _______________________

Medications

Name: _____________________________________Dosage ________________ For ____________________

___________________________________________Dosage ________________ For ____________________

___________________________________________Dosage ________________ For ____________________

___________________________________________Dosage ________________ For ____________________

___________________________________________Dosage ________________ For ____________________

__________________________________________  Dosage ________________ For ____________________

Allergies: _________________________________________________________________________________________

Return To Home Page