Membership Form
CSC 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
__________________________________________________________________
Survey