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)
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First Name *
Middle Name or Initial
Last Name *
Preferred Name
Gender
(select one)
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Birthdate *
(Note the calendar tool to the right of the date.)
MM
/
DD
/
YYYY
Retired?
(select one)
Living Status
(select one)
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Pets
(select if applicable)
Contact Information
Residence Address *
(be sure to include apartment number/letter somewhere, if applicable)
Street Address 2
(if needed)
City *
Zip Code *
(5 digits)
Mailing address if different from residence:
Home Phone *
example: 803-602-6434
Cell Phone
example: 803-602-6434
Work Phone
example: 803-602-6434
Email Address
Health
How would you describe your health?
(select one)
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Special Considerations
(Select all that apply.)
Additional Contact Information
Emergency Contact 1 *
Include Full Name - Relationship - Phone Number - Address
Emergency Contact 2 *
Include Full Name - Relationship - Phone Number - Address
Primary Care Physician
Include Full Name - Name of Medical Practice - Phone Number - Address
How did you learn about The FriendShip?
Would you be willing to be a Volunteer to assist other Members?
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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.)
Clear selection
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.)
Secondary Name if Household Membership
(if applicable)
Comments or questions:
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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