Charlestown Senior Citizens,Inc

999 Water Street

Charlestown ,IN. 47111

Membership Form

CSC Membership Form

1. 
   Membership Form

   Charlestown Senior Citizen,Inc.

   Membership Form Date ________

   Name_____________________________________________________

   Address____________________________________________________

   City_______________________________State_______ Zip________

   Telephone_________________________________________________

   Email(will not be distributed)________________________________

   Date of Birth _____________month________Day (year not required)

   Membership Fee: $10.00 lifetime

   _______ payment attached ( make checks payable to

   Charlestown Senior Citizen, Inc.)

   Check_____ Cash______  Other _______________

   Information:

   How Did you hear about Charlestown Senior Citizen,Inc? __________________________________________________________________________________________________________________________________________

   What program or activity would you like to see offered?

   __________________________________________________________________________________________________________________________________________

   Hobbies or Interest. ___________________________________________

   __________________________________________________________________

   Emergency Contact, if needed   Name, phone number

   __________________________________________________________________

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