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Membership Form

Please print and mail the form below along with your check payable to "55 Kip Center" - Rutherford residents $5, and non-residents $12.

I. Information About You
Name:
Address:
Town and Zip:
Telephone:
Work:
e-Mail:
Date of Birth:
Sex:
Past or Present Occupation:
Car *	(model/year/license plate #)-for Parking Sticker

Emergency Contacts
Name:
Address:
Telephone Home:
Telephone Work:
Relationship:


Name:
Address:
Telephone Home:
Telephone Work:
Relationship:

Your Doctor:
Telephone:
Hospital:
Medications:


Chronic Conditions: Please check all that apply
Asthma	Diabetes	Epilepsy	Kidney	Heart

Enrollments: Please check all that apply
Medicare	Social Security	PAAD	Veterans Benefits
Medicaid	Supplemental Social Security	Senior Housing

Marital Status:
Single	Married	Widowed	Divorced
Household Composition:
Live Alone	With Spouse	With Children	With Relative(s)

Race:
White	African American	Hispanic	Asian	Native American

How did you hear about 55 Kip Center?:

II. Membership
Wellness		Life Long Learning
Massage Therapy		Computer Classes
Stationary Exercise		Art
Aerobics		Creative Writing
Stretching and Toning		Current Events
Tai Chi		Bible Discussion
Choral Singing		Bridge
Dancing		Drama/Theatre
Yoga		Travel
Men's Fitness		Investments
Health Education		Insurance/HMO's
Nutrition		Employment Referral

III. Bridgebuilders

Bridgebuilders is an intergenerational volunteer program of 55 Kip Center. Opportunities for volunteerism exist in many different facets of our center. Would you like more information?

Yes No.

If yes, what are your skills and interests?

On Privacy

I understand that 55 Kip Center will make every attempt to respect my privacy and protect the confidentiality of the personal information provided. (Many of the questions are asked to provide statistical information for future funding).

On Membership

There is an annual membership fee of $12 ($5 for Rutherford residents). Please make checks payable to: 55 Kip Center. You will be issued a card that will entitle you to free parking, opportunities to participate in activities and programs and the Center calendar and newsletter.

Special Instructions

If you own a car and plan to drive to the center, a sticker will be issued to you for the window of your car. The sticker is only valid when the center is open and you must park in the designated area. Include all information about your car - model, year and license plate number.

Signature

Date

For Office Use Only:

Registration #
Car Permit #