Membership Application

 

KYLE AREA SENIOR ZONE APPLICATION

MEMBERSHIP APPLICATION

NAME: _________________________________________________________Date of Birth_________________

Address:___________________________________________________________Apt No:_______________

City: (       )________________________________State:______________         Zip________________

Phone: (       )_____________________Email:_____________________________________________________

Spouse Name:________________________________________________Date of Birth___________________________

Phone: (     )__________________________________________Email:_________________________________________

Are you a Veteran? _____   Spouse a Veteran? _____     Marital Status     ____ Married    _____Single           ___Widowed

EMERGENCY CONTACT INFORMATION

Name__________________________________________________Relationshihp________________________________

Primary Phone___________________________________________ Secondary phone _____________________

Doctor _________________________________________________Specialty____________________________________

Address_________________________________________________Phone_____________________________________

I assume any risk of harm or injury which may occur in any program at the Kyle Area Senior Zone (KASZ) facility and/or grounds. I release any and all volunteers, instructors, staff, or representatives of KASZ from liability, costs and damages, which may arise from participation in any program.

MEMBERSHIP

Individual Membership $10.00

PHOTO RELEASE

Should my photo be taken at any of the KASZ activities or events, they have permission to use it for publicity purposes which might arise from participation in any program. _____ Yes        _____No

TELL US MORE:

What was your occupation before retirement?__________________________________________________________

What talents (sing, play, direct –choir, band, plays) can share with KASZ members?_____________________________

Is there anything you can teach KASZ members__________________________________________________________

Are you able and willing to volunteer, when needed __yes   ___no   if so, what is your preference?

Signature __________________________________________________________Date___________________________

Signature___________________________________________________________Date___________________________

Board member__________________________Date________________    Payment     ________Cash        # _________Check

How did you hear about us?__Internet__Newspaper__Newsletter__Radio__friend__other

P.O Box 204 – 101 S Burleson, Kyle TX. 78640 / Phone 512-618-3536