Membership Form

    Please complete and sign the entire application form. All participant information provided is strictly confidential. *Information required for membership and funding.

    Personal Information

    Courtesy Title* (required)


    Marital Status* (required)

    Housemate Relationship

    Race* (required)

    Ethnic Background* (required)

    Household Income* (required)


    Lives Alone* (required)

    High Nutritional Risk* (required)

    Rural* (required)

    Disabled* (required)

    Physical Address* (required)

    Mailing Address

    (if different from physical)

    Contact Information

    *Either a home phone number or cell phone number is required.

    Email Newsletter

    Emergency Contact Information

    Please provide two emergency contacts.

    First Contact

    Second Contact

    Participation Policy and Waiver Consent

    Individuals wishing to participate in programs held by the Kennett Area Senior Center (the Center) should meet the following criteria to be considered appropriate for service provision:

    • Be able to feed and toilet themselves independently.
    • Be oriented to their current surroundings.
    • Behave in a non‐aggressive and non‐disruptive manner.
    • Desire to participate in a program or activity that is appropriate for them. Be able to clearly speak and socialize with others. Be able to ambulate safely.
    • Be able to self‐administer any medication(s) that are necessary while in attendance or make other arrangements.

    A complete copy of the participation guidelines and policies will be made available upon request by a participant or participant’s family member.

    Persons not meeting these criteria are welcome only if escorted by a responsible person at all times. This is required for the well‐being of all participants and staff participating in Center activities on or off the premises. The Center is not responsible for monitoring the activities of anyone visiting and /or participating in services or programs on or off the premises. Staff has the authority to make final decisions in all cases as to who is appropriate for participation in activities of the Center.

    I wish to take part in one or more events of the Kennett Area Senior Center and, to the best of my knowledge, information and belief, have no physical restraints which would prohibit my participation in the events. In consideration of my application for participation being accepted, I being legally bound, do hereby for myself, my heirs, my executors and administrators, waive and release any and all rights I may have against the Center, its directors, officers, agents, staff (paid or volunteer) and any other co‐sponsoring organizations for any and all injuries, claims, damages or causes of action, suffered by me during my participation in the events of the Center. The Center has my permission to have a physician attend me if it is deemed necessary for my health, welfare and safety. I attest and verify that I am in sufficiently good health for each activity, and understand the participation guidelines policy of the Center.

    I understand that during the course of a class, activity or program at the Center my photo or video may be taken by a representative of the Center. I release the Center to use this photo or video for the purpose of advertising as the Center deems appropriate.