Greenwich House
Please complete your online registration to become a FREE Older Adult Member at Greenwich House
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Name:
Email:
Comment:
Email Address
*
First Name
Last Name
Address
*
Phone #
Birthday
Month
/
Day
Marital Status
Single
Divorced
Widowed
Never Married
Lives Alone
Other
How many people are in your household?
US Veteran?
Yes
No
Emergency Contact (Please include full name and #)
I, declare, that I am at least 60 years of age.
Yes
No
Older Adult Center Preference
Center on the Square
Independence Plaza
Westbeth
Our Lady of Pompeii
Online Participant Only
Tell us your interests (Select all that apply)
Arts
Fitness
Music
Tech Support
Financial Literacy
Movies & Film
Language Classes
Trips / Outings
Socialization
Congregate Meals
Online Classes
Preferred format
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