The FriendShip -- Member Application
Before filling out this form, please note Membership Limitations
The FriendShip is not able to provide medical or personal care services, wheelchair transportation, services to those who live in a designated senior residence, or services to those with dementia.
Preferred Title
(not required)
First Name *
Your answer
Middle Name or Initial
Your answer
Last Name *
Your answer
Preferred Name
Your answer
Gender
(select one)
Birthdate *
(Note the calendar tool to the right of the date.)
MM
/
DD
/
YYYY
Retired?
(select one)
Living Status
(select one)
Pets
(select if applicable)
Contact Information
Residence Address *
(be sure to include apartment number/letter somewhere, if applicable)
Your answer
Street Address 2
(if needed)
Your answer
City *
Your answer
Zip Code *
(5 digits)
Your answer
Mailing address if different from residence:
Your answer
Home Phone *
example: 803-602-6434
Your answer
Cell Phone
example: 803-602-6434
Your answer
Work Phone
example: 803-602-6434
Your answer
Email Address
Your answer
Health
How would you describe your health?
(select one)
Special Considerations
(Select all that apply.)
Additional Contact Information
Emergency Contact 1 *
Include Full Name - Relationship - Phone Number - Address
Your answer
Emergency Contact 2 *
Include Full Name - Relationship - Phone Number - Address
Your answer
Primary Care Physician
Include Full Name - Name of Medical Practice - Phone Number - Address
Your answer
How did you learn about The FriendShip?
Your answer
Would you be willing to be a Volunteer to assist other Members?
Membership Types:
FULL MEMBERSHIP - - - - - - -
1 YEAR
$600 - Individual
$900 - Household (2 people)

ASSOCIATE MEMBERSHIP - - - - - - -
1 YEAR
$120 - Individual
$180 - Household (2 people)

I would like to join The Friendship as a . . . .
(Note: You can change your mind later, before paying a fee.)
Choose type of Full Membership, if applicable.
(Note: You can change your mind later, before paying a fee.)
Choose type of Associate Membership, if applicable.
(Note: You can change your mind later, before paying a fee.)
Primary Name on Membership *
(Enter Member's Name or Primary Member's Name.)
Your answer
Secondary Name if Household Membership
(if applicable)
Your answer
Comments or questions:
Your answer
The FriendShip
2827 Wheat Street
Columbia, South Carolina 29205

Phone: 803-602-6434
Website: www.thefriendship.org
E-mail: contact@thefriendship.org

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