GIRARD MULTI-GENERATIONAL CENTER
Rooted in Traditions, Talents and Technology
443 Trumbull Ave., Girard, OH 44420
330-545-6596

Applicant Information	
Last Name		First			M.I.		
Street Address		Apartment/Unit #		
City		State		ZIP		
Phone		Your Date of Birth:		
County			E-mail Address:		
Spouse’s Name if also becoming a member
		Spouse’s Date of Birth:	
Is your annual household income:		BELOW $10,830		BELOW $16,245		OVER $16,245	
What is your ethnic background?							
Do you currently exercise?	YES  	NO  	If yes, how often?			
How did you hear about the Center?	TV    	Newspaper  	Friend  	Neighborhood Express  	
family	
If you are purchasing a family membership, please furnish the names of your family members.	
Full Name		D.O.B.		
Full Name		D.O.B.		
Full Name		D.O.B.		
Full Name		D.O.B.		
Full Name		D.O.B.		
	
in case of emergency, please notify:	
Name		Phone	(               )	
Relationship		Address		
	
hobbies and interests	

membership and payment record	
Membership #				
Membership Type (Circle one):	Individual	Couple 	Family	
Check No.	     # _____________________                                         Check if paid in cash  	
Date of Payment:	Amount Paid $_______________________	
Disclaimer: The information provided on this form will be held confidential and used for statistical purposes only.	
*Center services and programs are funded by the Girard City Senior Levy and in part by the Trumbull County Senior Levy and Area Agency on Aging 11, Inc.