Mary Phillips Senior Center Membership Form

2. Membership Form
   MEMBERSHIP IS FREE AND IS OPEN TO ALL ADULTS AGE 55+

   MEMBERSHIP IS FREE AND IS OPEN TO ALL ADULTS AGE 55+

4. Main Contact - Member 1 Information

6. First Name*

7. Last Name*

9. Date of Birth*

10. Age*

11. Sex*

    1. Male
    2. Female

12. Veteran*

    1. Yes
    2. No

14. Address*

16. City*

17. State*

18. Zip Code*

20. Phone Number*

21. Alt Phone Number

23. Emergency Contact*

24. Phone Number*

26. Relationship*

28. Health Conditions*

30. Medications*

32. Spouse/Partner/Family Member 2 Information (if applicable)

36. First Name

37. Last Name

39. Address

41. City

42. State

43. Zip Code

45. Phone Number

46. Alt Phone Number

48. Emergency Contact

49. Phone Number

51. Relationship

53. Health Conditions

55. Medications

59. Photo/Video Release Consent*
    -- Select One --I hereby give my permission to use my image in City promotional materialI hereby do not give my permission to use my image in City promotional material

61. By selecting "I Agree" below, you acknowledge the following statement: “I certify that the above information is true and correct. I realize every precaution is taken to eliminate any injuries or hazards, and a competent supervisor is present; however, in the event of any injury, property damage, disability, death, sickness, or disease, I hereby waive, release and hold harmless from any liability for damages for personal injury including accidental death, sickness, or disease, as well as from claims for property damage which may arise in connection with the above named activity, the City of Temecula, its officers, agents, employees, volunteers and independent contractors. In case of accident or other emergency, personnel of the Community Services Department and/or its agents or independent contractors are hereby authorized to secure medical care deemed necessary as a result of accident or injury for the participant. I further agree to pay any and all costs incurred as a result of said treatment. I further permit the use of activity/event photography and/or video for media promotion.”*
    -- Select One --I Agree

Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field