Join Us – Salem Adult Citizens

Applicant Information

Name

First

Last

Date of Birth (mm/dd/yyyy)

Last 4 Digits of Social Security Number

Email

Mobile Phone

Home Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Mobile Member's Member

Veteran

Yes
No

Live Alone

Yes
No

Salem Baptist Church Member

Yes
No

Second Member in Same Household (if applicable)

Second Member's Membership Type

New
Renewal

Second Member's Date

Second Member's Name

First

Last

Second Member's Date of Birth (mm/dd/yyyy)

Second Member's Last 4 Digits of Social Security Number

Second Member's Email

Second Member Mobile's Phone

Second Member Home's Phone

Second Member's Veteran Status

Yes
No

Second Member's Salem Baptist Church Membership

Yes
No

Emergency Contact Information

Emergency Contact's Name

Emergency Contact's Relationship to You

Emergency Contact's Phone

Confidentiality Statement

Information about Salem Adult Citizens members, guests, and staff (including, but not limited to, medical, financial, personal, and legal data) is to be kept confidential. No information may be shared without the express written permission of the person in question. All donor information is considered confidential. All confidential information will be purged in accordance with regulatory guidelines.

I understand that during my volunteer service, I may be given access to confidential information. I understand that this information must not be shared or used outside of Salem Adult Citizens. In the event of my separation from volunteer service, whether voluntary or involuntary, I hereby agree not to utilize or exploit this information with any other individual or company.

Participant Eligibility Agreement:

Individuals wishing to participate in programs at Salem Adult Citizens must meet the following criteria: (Be able to feed and toilet themselves, Be oriented to their current surroundings, Be able to ambulate safely without assistance)

Signature:

Clear Signature

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Applicant Information

Second Member in Same Household (if applicable)

Emergency Contact Information

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Applicant Information

Second Member in Same Household (if applicable)

Emergency Contact Information

Form Key:

(*) - Input Required

() - Input Required*