Charlestown Senior Citizens,Inc
999 Water Street
Charlestown ,IN. 47111

"Age is an Attitude"

Membership Form

Charlestown Senior Citizen,Inc. 

Membership Form


Date _______________


Name_______________________________________________________________


Address _________________________________________________________________________


__________________________________________________________________________


___________________________________________________________________________


Phone Number (s)  Home _____________________________Cell ___________________________


Email    ________________________________________________

 ( Phone number or email will not be given out without your permission)


Date of Birth  _______/_______/_________ ( year not required)



In case of emergency while participating in activities with the organization, who should be contacted?


 Name__________________________________________________Relationship__________________


Phone ___________________________________________


 Name__________________________________________________Relationship _________________


Phone ____________________________________________



I give my permission to use my photo for publication by the organization. Check One.


[ Yes ] ________ [ No ]__________


How did you hear about CSC ?____________________Friend,________Web,________ Facebook


Hobbies or Interest____________________________________________________________________


_____________________________________________________________________________________


Membership Fee   $ 10 .00 lifetime


Payment attached ________    Cash _________ Check_________

(Make checks payable to Charlestown Senior Citizen,Inc.)



Revised 9-20-21


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