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?