Wilmington Senior Center Membership Application

Please fill out the application for our records. Note that the demographic information is required by our funding sources.

Today’s Date:

Date of Birth:

First Name: *

Last Name: *

Address: *

City: *

State: *

ZIP: *

Home Phone:

Cell Phone:

Email Address:

Employer or Previous Employer:

Preferred Method of Contact:

Phone

Mail

Other:

Are you currently volunteering?:

Yes

If “Yes”, where?:

Person to Call:

Relationship to You:

Phone:

Physician’s Name:

Physician’s Phone:

Marital Status:

Single/live alone

Single/live with Other(s)

Married

Income Range:

$0 – $11,000

$11,001 – $15,000

$15,001 – $19,000

Over $19,000

Wilmington Senior Center | 1901 North Market Street | Wilmington, DE 19802 | Monday – Friday 8:00am to 4:00 pm
Tel: (302) 651-3400 | Fax: (302) 651-3470 info@wilmingtonseniorcenter.org

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Wilmington Senior Center Membership Application