Shoreline-Lake

Shoreline-Lake Forest Park Senior Center Logo

Membership Form 2023

Single Membership: $40

Couple Membership: $70

Individual

$40

Couple

$70

Would you like to make an additional donation?

Choose amount

Contact information

First Name

Last Name

Phone Number

Address

City

State

Zip

Additional Information for Member #1

Date of Birth

Gender

Household Size

Number of Children Under 18 in Home?

What race do you identify with most?

Are you a veteran?

Are you disabled?

Are you an immigrant?

Do you speak limited English?

Are you homeless?

COVID-19 Vaccination Status

Income:

Ext. Low ($0 - $25,100)

Very Low ($25,101 - $41,800)

Low ($41,801 - $66,700)

Moderate ($66,700+)

Emergency Contact Name

Emergency Contact Phone

Doctor's Name

Doctor's Phone

If Household size 2, please fill out the following for Member #2

Member #2 First Name

Member #2 Last Name

Member #2 Phone Number

Member #2 Email

Member #2 Date of Birth

Member #2 Gender

What race do you identify with?

Is Member #2 a veteran?

Is Member #2 disabled?

Is Member #2 an immigrant?

Is Member # 2 Homeless?

Does Member #2 speak limited English?

Member #2 Covid-19 Vaccination Status

Member #2 Emergency Contact Name

Member #2 Emergency Contact Phone Number

Member #2 Doctor's Name

Member #2 Doctor's Phone Number

Are you family of a veteran?

Member #2 Are you Family of a Veteran

How would you like to pay?

This is a secure 256-bit SSL encrypted payment

Card Number

Expiration Date

CVV

I would like to cover the payment processing fee.

Donor hereby approves the payment of the charitable donation and/or purchase to Shoreline-Lake Forest Park Senior Center and in the amount set forth herein.

The charge will appear as "Sound Generations" on your credit card statement. Your membership will be applied directly to the center.

Choose amount

Contact information

How would you like to pay?

Total Amount