New Pricing CASC Membership Application

Central Area Senior Center
500 30th Avenue South | Seattle, WA 98144 | 206.726.4926
Membership Application

Please complete all information to the best of your ability. All information is kept confidential. *Demographic information helps us fund our programs and events by fulfilling reporting requirements for our various grants.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Type of Phone
E-mail
example@example.com
E-mail Opt-In
Gender
Sexual Orientation
Household Size
Reason for membership
Membership Background

*Demographic information helps us fund our programs and events by fulfilling reporting requirements for our various grants*
*Race/Ethnicity

Other
*Other status
Specify Other
*Income
Emergency and Medical Contact Information
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Doctor’s Name
Doctor’s Phone
Please enter a valid phone number.Format: (000) 000-0000.
Membership and Payment
Membership Type
Membership Status
Payment Plan
Payment Amount

prevnext( X )
USD
I release the Central Area Senior Center from any liability for any accident, injury, or damages of any kind to persons or property that might occur while participating in CASC activities.
Signature
Date

MonthDayYear
Date

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Membership Application