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Our Website MEMBERSHIP FORM
Whiteside County Senior Center
1207 West 9th Street
Sterling, IL 61081
Whiteside County Senior Center
1207 West 9th Street
Sterling, IL 61081
YOU DON'T HAVE TO BE A SENIOR TO BE A MEMBER !
Membership Application 2011 - (Website Form)
Name (s): _____________________________________________
Business Name: ________________________________________
Address: _____________________________________________
City / State ? Zip: _______________________________________
Telephone: _________________ Birthdate (s):________________
Emergency Contact: _____________________________________
Emergency Contact Telephone: _____________________________
Business Name: ________________________________________
Address: _____________________________________________
City / State ? Zip: _______________________________________
Telephone: _________________ Birthdate (s):________________
Emergency Contact: _____________________________________
Emergency Contact Telephone: _____________________________
( ) Enclosed is my membership fee in the amount of $10.00 for my individual membership.
( ) Enclosed is our membership fee in the amount of $15.00 for our joint membership.
( ) Enclosed is our business membership fee in the amount of:
( ) Enclosed is our membership fee in the amount of $15.00 for our joint membership.
( ) Enclosed is our business membership fee in the amount of:
( ) $25.00 Bronze
( ) $50.00 Silver
( ) $100.00 Gold
( ) Please find enclosed my additional donation in the amount of $___________
Your membership card entitles you to discounts on programs, services, special events, and trips !
Please return your membership form with your remittance to the center or mail in. Please pick up your membership card at the center.
Your membership card entitles you to discounts on programs, services, special events, and trips !
Please return your membership form with your remittance to the center or mail in. Please pick up your membership card at the center.
Official Use Only
Date Rcvd ______________________
Indv. __________ Joint ___________
Bus. _____________
Have received card ____________
Indv. __________ Joint ___________
Bus. _____________
Have received card ____________