| New Fairfield Senior Center
Registration Form NAME:_______________________________________DATE:__________________________ ADDRESS:___________________________________________________________________ CITY:__________________________________STATE:_____________ZIP:______________ MAILING ADDRESS (if different) ___________________________________________________________________________ PHONE NUMBER:____________________________________________________________ E-MAIL ADDRESS:____________________________________________________________ DATE OF BIRTH:_____________________________________________________________ NAME AND PHONE NUMBER OF PERSON TO CONTACT IN EMERGENCY: NAME:_________________________________________________________________ PHONE - HOME:_______________WORK:_________________CELL:_____________ HOW IS THIS PERSON RELATED TO YOU?_______________________________________ DO YOU HAVE ANY MEDICAL CONDITIONS THAT WE SHOULD BE AWARE OF? ______________________________________________________________________________ ______________________________________________________________________________ WHAT KIND OF ACTIVITIES WOULD YOU LIKE TO SEE INCLUDED AT THE SENIOR CENTER? ______________________________________________________________________________ ______________________________________________________________________________ DESCRIBE ANY HOBBIES OR SKILLS THAT YOU WOULD LIKE TO SHARE WITH OTHERS ______________________________________________________________________________ ______________________________________________________________________________ Please complete and return to the New Fairfield Senior Center Once submitted you will our receive bi-monthly newletters and ID card to use when you visit the center |
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