Membership Form – Individual – Wallingford Community Senior Center

Member Information

First Name *

Last Name *

Email Address *

Primary Phone *

Secondary Phone

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code *

Birthdate *

Emergency Contact

Optional Demographic Survey

Your OPTIONAL responses to the following questions help Wallingford Community Senior Center receive valuable funding from our sponsoring government entities. We will not, under any circumstances, share your personal information with other individuals or organizations. We do not sell, communicate or divulge your information to any mailing lists. Please respond to the best of your ability. Please scroll to the bottom and click "Submit and Pay Now" if you prefer not to respond.

Please scroll to the bottom and click "Submit and Pay Now" if you prefer not to respond.

Do you consider yourself a single adult living alone?

YesNoNo Reply

Do you consider yourself in a household with children under 18?

YesNoNo Reply

Do you consider yourself a veteran?

YesNoNo Reply

Do you consider yourself a person with a disability?

YesNoNo Reply

Do you consider yourself limited English speaking?

YesNoNo Reply

Do you consider yourself unhoused?

YesNoNo Reply

Please self-identify your race:

Please self-identify your sexuality:

Please self-identify your gender:

Do you consider yourself to be transgender?

YesNoNo Reply

Please consult the following chart to determine your Household Income Level:

Please indicate your Household Income Level

ABCD

Congratulations! You have qualified for a Reduced Rate (free) membership! After clicking "Submit and Now" you may close the pop-up payment tab, as your membership will be completed!

(206) 461-7825

Membership Form – Individual

Member Information

Optional Demographic Survey

Please scroll to the bottom and click "Submit and Pay Now" if you prefer not to respond.

Do you consider yourself a single adult living alone?

Do you consider yourself in a household with children under 18?

Do you consider yourself a veteran?

Do you consider yourself a person with a disability?

Do you consider yourself limited English speaking?

Do you consider yourself unhoused?

Do you consider yourself to be transgender?

Please indicate your Household Income Level

Congratulations! You have qualified for a Reduced Rate (free) membership! After clicking "Submit and Now" you may close the pop-up payment tab, as your membership will be completed!

Enter your email address, indicate what type of information you would like to receive, and click or tap "Sign up" to begin receiving WCSC's bi-weekly E-Newsletter:

Enter your email address, indicate what type of information you would like to receive, and click or tap "Sign up" to begin receiving WCSC's bi-weekly E-Newsletter: