Date:   _________________________
                             Month / Day / Year
       LAST NAME:                                          FIRST NAME:
       Street:                                             Telephone # :
       City:                        Province:              Cell phone # :
       Postal Code:                                        Email :
       G50+ Seasonal Program / Newsletter via email?                     Yes                   No         
       BIRTHDAY:                                     BIRTH YEAR:                 GENDER:
                              (Month / Day)
                                             EMERGENCY INFORMATION
       CONTACT:                                            Cell phone # :
       RELATIONSHIP:                                       Home phone # :
                                                           Work phone # :
                                               MEDICAL INFORMATION
       (If you are not fully self-sufficient, you must have your own personal support worker [PSW] present while
                                     at the Centre to see to your personal needs)
       Do you hold a Para Transpo Card?            Yes               No     Para #
       Please provide the dates of your COVID 19 Vaccinations:
       If you have any medical / personal information you wish us to be aware of, please list below:
                                PRIVACY, PHOTOGRAPHY AND MEMBERSHIP WAIVER
          (We protect and respect your privacy.  Your personal information is used to communicate within our
                   organization.  We do not provide or sell this information outside our organization.
       Photograph Permission:  Photographs may be taken on occasion and used in publicity materials including the 
       G50+ website.  Media representatives may attend events and publish or broadcast photographs and video.  
       Other participants may take photographs and/or video and that G50+ has no control over how these are used.
       General Membership Waiver:  I hereby agree to release, absolve and hold harmless the Gloucester 50+ 
       Centre, its members, directors, employees, independent contractors and agents connected with the Centre from 
       and against any blame and liability for any injury, including Corona Virus Covid 19, loss, inconvenience or 
       damage hereby suffered or sustained as a result of participation in any activity at the Centre in person or Virtually.
                           (Date)                                          (Applicant’s Signature)
                                                 OFFICE USE ONLY
         Mem Year:  2021 / 2022  Method of Payment:
                                                     MC          Visa    etrans    Cheque    Cash
        MSC        Membership Binder       POG      Name Tag    Par Q   MSC ID Card
                Numerical   Alphabetical                                              Volunteer /
                                                                                      Staff Initial
       Option in MSC:___________