Membership Application

Section 1: Member Information

Section 2: Residency Status

Select one

I live in Dorchester County – Membership is FREEI live outside Dorchester County – Annual Membership Fee: $25

Section 3: Emergency Contact (Optional)

Emergency Contact 1

Name

Relationship

Primary Phone

Secondary Phone (Optional)

Emergency Contact 2

Name

Relationship

Primary Phone

Secondary Phone (Optional)

Section 4: Medical & Safety Information (Optional)

Medical Conditions Staff Should Be Aware Of in an Emergency

Mobility Assistance Needed

NoneCaneWalkerWheelchairOther

If Other, please specify

Section 5: Program Interests (Optional)

Select all that apply

Fitness ClassesCongregate DiningHome Delivered MealsArts & CraftsCeramicsTechnologySocial EventsVeterans ProgramsVolunteer OpportunitiesIntergenerational ProgramsOther

If Other, please specify

Section 6: Hobbies & Expertise (Optional)

Former Occupation(s)

Skills / Certifications / Trades

Languages Spoken (Optional)

Would you be interested in (select all that apply)

Teaching a classVolunteeringMentoringSpecial Events SupportAdvisory GroupNot at this time

Section 7: Optional Demographic Information

All demographic information is voluntary and used only in summary form to help Dorchester Seniors, Inc. obtain funding and improve services.

Race/Ethnicity (Optional) — select one or more if applicable

African AmericanWhiteHispanic/LatinoAsianNative AmericanOtherPrefer not to answer

If Other, please specify

Veteran Status (Optional)

VeteranSpouse of VeteranNot a Veteran

Annual Household Income Range (Optional)

Under $25,000$25,000–$49,999$50,000–$74,999$75,000+Prefer not to answer

Section 8: Photo Release

Select one

YES – I give permission for DSI to use my photo/video for marketing and funding purposes.NO – I do not give permission.

Member Signature (Photo Release) (Type Full Name)*

Date (Photo Release)*

Section 9: Liability & Participation Agreement

I understand that participation in DSI activities is voluntary. I assume responsibility for my own wellbeing and release Dorchester Seniors, Inc., its Board, staff, and volunteers from liability except in cases of gross negligence.

I agree to follow all center policies and contribute to a respectful environment.

I have read and agree to the Liability & Participation Agreement above.

Member Signature*

Clear

Date*