Request edit access
Whiteside County Senior Center Membership
Your membership with the Whiteside County Senior Center not only offers you a wide array of activities but it also helps our organization thrive. The Whiteside County Senior Center offers two membership options: standard and plus.

Both of these membership options offer an array of quality programs and services to further our mission of promoting the well-being of our county's senior citizens, encouraging their involvement in community life and supporting their independence. Our staff is committed to ensure our members have a positive and enjoyable experience at our facility.

PERSONAL INFORMATION
First, Middle & Last Name *
Your answer
Address, City, State & ZIP Code *
Your answer
Home Phone Number
Your answer
Cell Phone Number
Your answer
Email Address
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Please list anything our staff should be made aware of (i.e. medical conditions such as seizures, or special accommodations).
Your answer
EMERGENCY CONTACT INFORMATION
Emergency Contact First, Middle & Last Name *
Your answer
Emergency Contact Address, City, State & ZIP Code *
Your answer
Emergency Contact Phone Number *
Your answer
Emergency Contact Relationship To You *
Your answer
MEMBERSHIP OPTIONS, SIGNATURE & PAYMENT
Please choose your membership type. *
If choosing one of the Couple membership options, please enter your spouse's name.
Your answer
By typing your full name below you are signing this form and acknowledging that you have read and received a copy of the Whiteside County Senior Center's Patron Handbook (available on our website under the Member section), and that you agree to abide by those policies and procedures. *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Whiteside County Senior Center. Report Abuse - Terms of Service