Center

Questions marked with an * are required

* First Name :

* Last Name :

* Address 1 :

Address 2 :

* City :

* State :

* Zip :

* Phone :

* Email Address :

What is your date of birth?

Please list activities/events/hobbies you would like to have offered at The Center?

Please list any hobbies/talents/activities that you would be willing to teach or facilitate at the Center?

Would you be willing to pay a yearly membership fee (less than $50)to participate in activities at the Center?

Yes

Please rank (1-5) the following in order of interest:

Intergenerational Activities
Movies/Theater
Health & Fitness
Gardening
Speakers/Presentations

Please rank (1-4) the times of day you would like to attend movies/activities/speakers(1 being the best time and 5 being the worst time :