Author: Autumn

OREGON SENIOR CENTER
Membership Application through 12/31/2026
Annual membership begins on January 1 and expires on December 31. New members are welcome at any time. Please check appropriate membership category.
- - OR - -
We welcome special supporting contributions. We will acknowledge these general contributions by placing the donor’s name on display in the Center during the membership year.
INDIVIDUAL MEMBERSHIP OR PERSON 1
PERSON 2 (Spouse if applicable)
EMERGENCY CONTACT INFORMATION (MUST BE COMPLETED)
White___ Hispanic___ African-American___ Native American___ Asian____
Please answer these questions. Your answers will help your Senior Center obtain grants and financial
Contributions to grow and help curb the cost of dues.
Rural: Yes___ No___ Number of Persons in Household______ Monthly Income_______________
Do you consider yourself at or below poverty level? Yes________ No________

BOOSTER Membership (60 & over, with voting rights):	_______ $25/Individual	_______ $35/couple
NON-RESIDENT or SUPPORTING Membership (under 60, without voting rights):	_______ $35/Individual	_______ $50/couple

______$50.00 Bronze-Level Support Member	______$250.00 Diamond-Level Support Member
______$75.00 Silver-Level Support Member	______$500.00 Platinum-Level Support Member
______$150.00 Gold-Level Support Member

Date_______________	Male__________	Female__________
Last Name________________________________		First Name__________________________________
Last 4 Digits of SS__________		Birthdate_____________

Address ___________________________________________________________________________________________________

City________________________________________	State__________	Zip______________
Home Phone________________________________		Cell Phone______________________________

Date_______________	Male__________	Female__________
Last Name________________________________		First Name__________________________________
Last 4 Digits of SS__________		Birthdate_____________

Last Name _______________________________________	First Name _______________________________________________
Home Phone _____________________________________	Cell Phone _______________________________________________
Last Name _______________________________________	First Name _______________________________________________
Home Phone _____________________________________	Cell Phone _______________________________________________
Primary Physician__________________________________	Phone ___________________________________________________

PHOTO RELEASE FORM
I hereby grant permission to The Oregon Senior Center to use photographs and/or video of me taken in publications, news releases, online, and in other communications related to the mission of The Oregon Senior Center.
Name _____________________________
Address ______________________________
State ___________________Zip Code_______________________
Phone (day) ___________(evening) ___________
Email Address (optional) _________________________
Signature Date_________________
(Signature of Adult, or Guardian of Children under age 18)
Thank you!