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2. Lymes' Senior Center Membership Form
4. Name*
5. Birthdate*
   Birthdate
6. Gender*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
16. Email Address*
18. Veteran Status*
    -- Select One --Yes, I am a VeteranYes, my spouse is a VeteranNo, neither myself or my spouse is a Veteran
19. Marital Status*
    -- Select One --MarriedSingleWidowedDivorcedPartnership
20. # in Household*
22. Would you prefer to receive your monthly newsletter by email or mail?*
    -- Select One --EmailMail
26. Emergency Contact Information

    Who can we contact in case of an emergency?

28. Name*
30. Phone Number*
31. Relationship*
35. Payment Information

    If you are a resident of Lyme or Old Lyme, membership is $5.00 per person, per year. If you are a resident of another town, membership is $10.00 per person, per year. You can become a member for multiple years at a time, just adjust your payment! Payments can be cash or check, and made payable to "Lymes' Senior Center". Payments can be mailed in, or dropped off to us at the Lymes' Senior Center (26 Town Woods Road, Old Lyme, CT 06371)

37. Questions or Comments?

    If you have any questions or comments regarding membership, what we offer, or to register for programs, feel free to leave them in the allotted space! We will get back to you in the order we receive them!

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38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field