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My Senior Center Registration Form
Registration form for Senior Coastsiders participants
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Middle Initial
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Prefer not to say
Other:
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
PO Box
Your answer
Cell Phone
*
Your answer
Home Phone
Your answer
Email
*
Your answer
Do you live alone?
Yes
No
Clear selection
Marital Status
*
Single
Married
Widowed
Divorced
Prefer not to state
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Prefer not to state
Race
*
African American/Black
Asian
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
White
Prefer not to state
Regarding your participation, please check all that apply:
*
I participate in classes/events in person at Senior Coastsiders ONLY.
I participate in classes/events virtually (Zoom etc.) ONLY.
I participate in classes/events but sometimes I come to the SC, and sometimes I do classes over Zoom.
I volunteer.
Required
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