NAME: DATE OF BIRTH:
(MINIMUM AGE – 55)
ADDRESS:
HOME PHONE: CELL PHONE:
E-MAIL ADDRESS:
RACE: o Caucasian o Hispanic o African Amer. o Native Amer. o Asian o Other
MARITAL STATUS: GENDER: M F
LIVING ARRANGEMENTS: o Alone o With Spouse. o With Family o Other
PRIMARY DOCTOR: PHONE:
DO YOU USE: o Wheelchair o Walker o Cane o Scooter o Other
HEALTH PROBLEMS:
FOOD and/or MEDICINE ALLERGIES:
EMERGENCY CONTACT INFORMATION (1)
NAME: RELATIONSHIP TO YOU:
PHONE NUMBERS: Home: Cell: Work:
EMERGENCY CONTACT INFORMATION (2)
NAME: RELATIONSHIP TO YOU:
PHONE NUMBERS: Home: Cell: Work:
*******
INFO SHARING PERMISSIONS
I give permission for my information to be shared with other Members as follows:
o PHONE o MAILING ADDRESS o E-MAIL ADDRESS
o AS CHECKED ABOVE, BUT ONLY FOR THE FOLLOWING GROUP(S):
o DO NOT SHARE PLEASE SIGN HERE:
********
Yearly Membership runs from July 1st to June 30th
Membership is required to participate in programs, classes, activities and events at the Senior Center
as well as for transportation, hairdressing services, Massage Therapy and utilizing different rooms in the building.
Norwich Residents: Suggested $25 yearly Membership*
Out of Town: $40 yearly Membership
*Financial Assistance Available For Norwich Residents (Please Call for Information)
All Member information is kept Confidential and used only for the purposes of notifying you about services;
in case of an emergency; and for statistics about the use of the Senior Center required by the City of Norwich.
The Rose City Senior Center is a Nonprofit Organization, which is funded through the Municipal Budget from the City of Norwich and through grant funding. The Membership Fee is a necessary ingredient to the successful operation of the Senior Center in order to provide numerous and diverse programs. Revenue from Membership Fees stay with the Senior Center and goes directly towards programming and other services offered.
