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