Edward King House Senior Center Membership Drive 2023-24

Personal Information

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:
• Cell Phone:
• * Emergency Contact:
• * Relationship to Member:
• * Emergency Phone:

• Fee

  Type	Fee
  Event fee	$30.00
  Event fee type 2	No Charge

Member Information

• * What is your birthdate? Enter Year First

Member Information

• *

  What is your gender?

  • Woman
  • Man
  • Non-Binary/Non-Conforming
  • Transgender
  • Prefer Not to Respond
• *

  What is your race/ethnicity?

  • White
  • Black or African American
  • Asian
  • American Indian or Alaskan Native
  • Native Hawaiian or Other Pacific Islnader
  • Hispanic or Latino
  • Non-Hispanic or Non-Latino
  • Prefer Not to Respond

EKHSC Parking Sticker Application: Fill out the fields below if you would like a parking sticker.

• Year of Vehicle:
• Make of Vehicle:
• Model of Vehicle:
• Color of Vehicle:
• State and License Plate Number:

Add A Guest

You may add a maximum of 1