June Newsletter and Calendar - City of Montpelier, Vermont
June Newsletter and Calendar - City of Montpelier, Vermont
June Newsletter and Calendar - City of Montpelier, Vermont
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Members: We have a new database, <strong>and</strong> it’s time to update your information. Thanks for your<br />
cooperation in cutting out, completing, <strong>and</strong> returning the following form to us (front <strong>and</strong> back!).<br />
Blank copies available at <strong>of</strong>fice <strong>and</strong> on website, too!<br />
7<br />
<strong>Montpelier</strong> Senior Activity Center: Member Dues Renewal FY14<br />
THANK YOU FOR PAYING YOUR ANNUAL DUES <strong>and</strong> for<br />
helping us update important information for our records!<br />
Today’s Date___________________ Date <strong>of</strong> Birth_______________ Gender _______<br />
NAME: First ______________________ Middle___ Last _______________________<br />
NICKNAME or other name instructions:_______________________________________<br />
MAILING ADDRESS______________________________________________________<br />
TOWN/CITY, STATE, ZIP__________________________________________________<br />
TOWN/CITY OF RESIDENCE (if different from mailing)_________________________<br />
Do you live elsewhere part <strong>of</strong> the year If so, please tell us which months <strong>and</strong> your other address:<br />
_________________________________________________________________<br />
Home Phone______________ Cell________________ Other Phone________________<br />
E-MAIL__________________________________________________________<br />
Do you live with another MSAC member (This information helps us streamline print mailings<br />
<strong>and</strong> save postage)___________________________________________________<br />
How do you prefer to receive the MSAC monthly newsletter, Action Times (email only saves us nearly $1/<br />
month in printing <strong>and</strong> postage) (Always posted online at www.montpelier-vt.org/msac)<br />
Via e-mail ____; USPS____; Both_____<br />
Emergency Contact Person___________________________ Relationship________________________<br />
His/her telephone <strong>and</strong> address_________________________________________________<br />
Do you have any special health issues or disabilities about which we should be aware ___________<br />
_____________________________________________________________________________________<br />
Allergies / Dietary Restrictions__________________________________________________________<br />
Please read <strong>and</strong> sign the following MSAC Release <strong>of</strong> Liability Statement, which we will keep on file:<br />
I assume all risks <strong>and</strong> hazards incidental to participation in activities at MSAC <strong>and</strong> MSAC-sponsored activities<br />
<strong>of</strong>f-site, including transportation to <strong>and</strong> from activity, <strong>and</strong> I hereby waive, release, absolve, indemnify, <strong>and</strong><br />
agree to hold harmless the <strong>City</strong> <strong>of</strong> <strong>Montpelier</strong>, the <strong>Montpelier</strong> Senior Activity Center, their <strong>of</strong>ficers, agents, <strong>of</strong>ficials,<br />
employees, volunteers, organizers, partners, sponsors, supervisors <strong>and</strong> participants for any acclaim arising<br />
out <strong>of</strong> an injury to myself.<br />
Signature_____________________________________________ Date_____________________________<br />
Are you employed No, retired____; No, between jobs___; Yes, Full-time___; Yes, Part-time___<br />
What are your reasons for being a member On-site Classes__ ; Off-site activity Discounts__; Trips__; Access<br />
to facility for no-fee activities/games___; Other (please describe)_____________________________<br />
Are there any new activities, programs, or services you would like to suggest<br />
________________________________________________________________________________________<br />
OVER, PLEASE→ ONE MORE PAGE→