HomeMy WebLinkAboutMember Registration Form_Version_1-25-2023
Member Registration Form
Notice: All information collected by The Center, except personal medical information, is considered to be a public record in
the State of Iowa. The Center will only share membership information when compelled to by law.
Version 1/25/2023 Over
Personal Information
First Name Last Name
Address City State Zip
Are you an Iowa City Resident (within City limits)?
Yes No
Do you live in an unincorporated part of Johnson County?
Yes No
Primary Phone Number Secondary Phone Number
Email
Date of Birth (mm/dd/yyyy) Gender Identity Names of household members sharing your membership
Emergency Contact Information
Emergency Contact Name Relationship Phone Number
Correspondence
I would like the program guide calendar:
Emailed to me Mailed to my home I will pick up at the Senior Center I do not wish to receive one
Optional Information
How would you describe your race/ethnicity? (check all that apply)
Asian Black or African American Hispanic or Latino Multi-racial Native American/Alaskan
Pacific Islander White Self-identify: ______________________
What is the primary language spoken in your home?
English Spanish Arabic Chinese French Other Language: __________________
Suggestions for Future Classes/Activities:
Please indicate your household income level according to the number of people in your home:
1 person 2 people 3 people 4+ people
□ Less than $20,950
□ $20,951 - 34,900
□ $34,901- 55,850
□ More than $55,80
□ Less than $23,950
□ $23,951 - $39,900
□ $39,901 - $63,800
□ More than $63,800
□ Less than $26,950
□ $26,951 - $44,900
□ $44,901 - $71,800
□ More than $71,800
□ Less than $29,900
□ $29,901 - $49,850
□ $49,851 - $79,750
□ More than $70,751
Release and Waiver of Liability
I hereby, for myself, heirs, executors, and administrators, waive, release, discharge, covenant not to sue, and to hold
harmless the City of Iowa City, its officers, employees, and agents from any and all claims for damages, demands and
causes of action of every nature which I may have or which may hereafter accrue to me arising either directly or indirectly
from my participation in, or use of, programs, activities and services, including but not limited to the exercise room, at the
Iowa City/Johnson County Senior Center, 28 South Linn Street, Iowa City, Iowa.
I have read this release and waiver of liability and agree to and accept its terms.
____________________________________________ ____________________________________________
Printed Name Signature
______________________
Date
Volunteer Information Date:
Are you interested in volunteering at the Iowa City Senior Center?
Yes No Maybe Later:
If yes, what are your areas of interest?
Instructor/Presenter Group/Club Leader Advisory/Working Committee Building Supervisor
Tax Aide Counselor SHIIP Counselor Technology Mentor SCTV Producer Library Quilter
Intergenerational Programs Special Events Short-Term Projects Other:
Comments, past experience, related training/skills:
Return this form to: Iowa City Senior Center ● 28 S Linn St, Iowa City, IA 52240 ● 319-356-5220
Annual Membership Fee
Low-income membership discounts are available. Call Kristin Kromray at 356-5221 for eligibility details.
Iowa City Resident
(within City limits) Non-Iowa City Resident Subtotal
Single Membership: $40 $75 $
Additional Household Members: $25 each $45 each $
I would like to make a donation of $____________ to the Iowa City/Johnson County Senior Center. $
Total Due: Payable to the Senior Center by cash, check, or Visa/MasterCard/Discover (in person) $