Membership
Application
Form


advertisement

Membership
Application
Form
Submit
this
form
with
a
check
for
$18
for
membership
dues,
to:
ElderQuest
101
Boone
Hall
Eastern
Michigan
University
Ypsilanti,
MI
48197
Basic
Information:
First
Name:
Street
Address:
City:
Last
Name:
Date:
________________________
State:
Apartment
#:
Zip:
Home
Phone:
____________________
Email:
Cell
Phone:
___________________
Date
of
Birth:
___________________
Are
you
interested
in
receiving
an
e‐newsletter?
How
did
you
hear
about
ElderQuest?
Yes
No
What
do
you
hope
to
gain
from
your
involvement?
Academic
Information:
Are
you
applying
for
academic
study?
E‐Number:
E__________________
Yes
No
(If
no,
skip
this
section)
Level
of
Academic
Study:
Area
of
Academic
Study:
Are
you
currently
registered
for
classes?
Volunteer
Information:
Are
you
interested
in
volunteering
through
ElderQuest?
In
what
areas
would
you
like
to
volunteer?
Do
you
have
a
car?
Yes
No
(If
no,
skip
this
section)
Would
you
be
willing
to
carpool?

Download