Young at Heart Activity Center Membership Enrollment

Name (First, Last) (required)

Street Address (required)

City (required)

State/Province/Region (required)

Zip Code (required)

Home Phone (required)

Mobile Phone (required)

Email (required)

Date of Birth (required)

Select the Young At Heart Activity Center You Would Like to Join: (required)
CentralLiberty

I am interested in (required)
Membership ($25 per year per individual/$35 per couple)Health ScreeningsFitness/ExerciseSupport GroupsEducational WorkshopsInsuranceFinancial PlanningLegal ServicesConsumer ProtectionArts/CraftsGamesMusicDanceDay TripsEducational ClassesVolunteer OpportunitiesOther
Other

Help Us To Get To Know You Better

Gender: (required)
MaleFemale

Race: (required)
American IndianAsianBlackPacific IslanderWhite

Ethnicity: (required)
Hispanic or LatinoNot Hispanic or Latino

I am: (required)
SingleMarriedWidowed

I live: (required)
AloneWith Friend/RoommateWith SpouseWith ChildrenWith Other Family Members

Years lived in the area: (required)
New to the Area1-5 Years6-15 YearsAll My Life

I am: (required)
RetiredWorkingA Caregiver of a Spouse or ParentA Veteran

Previous Occupation (required)

How many children do you have if any?

How many grandchildren do you have if any?

Do you have any pets? (required)
YesNo

If yes, tell us more:

Name of place of worship, if any:

How did you hear about the Young at Heart Activity Center? (required)
WebsitePresentationFriends/FamilyOther

Do you have a special skill(s) that you would like to share as a course instructor or special presentation?

Are there programs and/or services that you would like to see the Center offer?

Photo Release

The Young at Heart Activity Center likes to include photographs of members enjoying life with each other in various publications, website and other social media. Please let us know by indicating below if you DO or DO NOT want the Young at Heart Activity Center/Meals on Wheels to use your picture in promotional pieces. (required)

It is OK to use my photograph in promotional pieces, including print and social mediaPlease do not use my photograph in promotional pieces, including print and social media