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Senior Scope of Trumbull County |
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Membership Yes, I want to be a member of SCOPE, Inc. (Senior Center & Services). I am over 50 years of age. It's very important that we have your complete address including street directions (NE, NW), apartment numbers and zip codes to ensure you get your SCOPE mail. Membership fee is $12, please send a check, along with a printout of this form to the center you would like to join. NAME : ________________________________________________ STREET: _________________________________________________ APARTMENT NUMBER: ___________________ CITY: ____________________________ STATE:
___________________ BIRTH DATE: __________________________________ DIABETIC: _____ YES _____NO NEXT OF KIN: ___________________________ PHONE: ________________ DOCTOR: ________________________________ PHONE:_________________ RETIRED: _____ YES _____ NO IF YES, FROM WHERE? ____________________________________________ HOBBIES: ________________________________________________________
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