Membership

Senior Action is committed to helping middle income seniors access appropriate, affordable services by:

• Providing services to meet needs (i.e. transportation, meals, home care)

• Providing social engagement and life meaning through volunteerism and planned activities

• Providing health and fitness programs and services.

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Take advantage of the many programs and services we have to offer.
Please fill out the form below and click 'Submit' to make payment securely online.  Or, click here to print and mail your application.

                         *required fields

*Name:
*Date of Birth (xx-xx-xxxx):	- -
*Retired?	Yes       No
*Race:	*Gender:    Male    Female
*	Single   Married   Widowed   Divorced
*Do you live:	Alone   With Family   Other
Military Veteran?	Yes    No
*# in Household:
*Address:
*City:
*State:	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*Zip:
*Home/Cell Phone:	- -
*Email:
*Doctor's Name:
*Phone:	- -
Emergency Contact
*Name:
*Relationship:
*Home/Cell Phone:	- -
Work Phone:	- -
	I, , understand / consent to releasing personal information to Senior Action for the purpose of assessing my needs and developing services for me.  I am assured that this information will remain confidential and will not be released beyond the expressed use of our agency.
	INDIVIDUAL MEMBERSHIP $24	COUPLE MEMBERSHIP $40 (Living in same household)       (below information required)
Additional Name:
Date of Birth (xx-xx-xxxx):	- -
Retired?	Yes       No
Race:	Gender:    Male    Female
	Single   Married   Widowed   Divorced
Do you live:	Alone   With Family   Other
Military Veteran?	Yes    No
# in Household:
Address:
City:
State:	Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Home/Cell Phone:	- -
Email:
Doctor's Name:
Phone:	- -
Emergency Contact
Name:
Relationship:
Home/Cell Phone:	- -
Work Phone:	- -
	I, , understand / consent to releasing personal information to Senior Action for the purpose of assessing my needs and developing services for me.  I am assured that this information will remain confidential and will not be released beyond the expressed use of our agency.