Membership Application

Please Print



Name: ___________________________________________________________


Address: _________________________________________________________


Town + Zip: ___________________________Phone: _____________________


Birth Date: ____________________________(Year Optional)


My interests are: (check those that apply)


Social Contacts: _____ Trips: _____ Cards: ______ Bingo: _____


Lunch Program: ______ (If you checked this, answer A, B, C & D)


A: Diabetic _____ B: Skim Milk _____ C: Regular Milk _____


D: Can you help in kitchen one day a month? Y ___ N ___


Other interests: _____________________________________________________

Do you have any talents that may be useful to our program, such as playing piano, singing, knitting, crocheting, teach crafts, etc.


Describe: __________________________________________________________


Person to notify in case of emergency: ___________________________________


Address: _____________________________________Phone: ________________


Town & Zip: __________________________________


The Officers of the Windham Seniors welcome you to our family. We hope that you have an enjoyable experience. Any suggestions to improve our organization will be appreciated.