WINDHAM SENIORS INC

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.