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This form can be printed
and mailed or faxed to WCC with payment, OR call 923-1802 and an
application can be faxed or emailed to you. Membership fees
are due on your anniversary date each year.
Waikiki Community Center Member
Application
Last Name:
___________________ First Name: ______________ Date:
___________
Birthdate: __________
E-mail: _____________________ Local
Phone_____________
2nd Member Name:
_______________________________ 2nd
Birthday_____________
Local Address:
_________________________________________________________
Street
Apt. #
City
State
Zip Code
Permanent:
____________________________________________________________
Street
Apt. #
City
State
Zip Code
Emergency Contact Name:
____________________________ Phone:
_____________
Preferred hospital/clinic in
the event of an emergency:
__________________________
Are you allergic to
anything? ____________________________ Health
Provider____________________
Would you like to
receive your member newsletter via __ E-mail __ US Mail ___ Both ___ Do not
send
Please check one
category:
Per Year
____ INDIVIDUAL (54 and younger)
.…………………………………………………………………… $ 30.00
____ OHANA (Couples, parents and
Guardians) ……………………………………………………… $ 50.00
____ SENIOR INDIVIDUAL (55 and
older) …………………………………………………………….. $ 25.00
____ SENIOR OHANA (Couples,
parents and Guardians)…………………………………………… $
35.00
____ FRIENDS OF
WAIKIKI
COMMUNITY
CENTER
___ $1000
Benefactor
___$500 Supporter ____ $ 250
Partner
____ $ 100
Friend
Your membership
supports our community and brings to you fellowship and new
opportunities!
INTERESTS – Check as
many as apply:
____ Other______________________
____ Senior Citizen Programs
____ Childcare Programs
____ Community Classes
____ Community Activities
____ Volunteer Activities
____ Computer
Classes
____ Intergenerational
Programs
____
Newsletter
____ Health/Wellness
Programs
____
Travel/Excursions
What is your main reason
for joining today?
______________________________________________________________________
How did you hear about
WCC? Word of mouth Friends Media Newspaper
___Other______________
HAWAII
RESIDENT? (Registered voter/Pay
Hawaii State Taxes) Yes/No If no, how many months do
you live in Hawaii? __ Months. What months of year?
_________ Send
newsletter to 2nd address? Y/N
Please answer the
following questions, which will enable WCC to better provide
programs and services to meet the needs of its members. INFORMATION IS FOR
STATISTICAL PURPOSES ONLY, AND WILL BE KEPT COMPLETELY
CONFIDENTIAL.
Marital
Status:
(Please circle)
Single
Married
Separated
Divorced
Widow
Gender:
Male/Female
Highest Education Level
Completed (Please circle one)
Elementary 7 8 9
10 11 12 13 14 15 16 17 18 19 20+
Ethnic
Background: (Please circle those
that apply): African
American
American Indian Caucasian Chinese Filipino Hawaiian Hispanic Japanese Korean Pacific Islander Vietnamese
Other______________________
Age Group:__Teen (10-19 yrs)
__Young Adult (20-34 yrs) __Middle Age (35-55
years) __Senior
(56-70) ___Elderly
(71+)
Household
Income:
__ Up to $29,799 per year
__ Up to $47,679 ___ Other (above
$47,680)
Military/Federal
___Military list
Branch_____________ Rank____ Coast Guard? Y/N
Civilian
Employee?
Y/N
Please list any special
conditions you may need____________ Are
you currently a Federal Employee? Yes/No
Wheelchair assistance, hearing, sign language,
etc.
PLEASE
COMPLETE AND SIGN THE BACK OF THIS FORM Thank
you
page
2...
MEMBER
RELEASE
(Classes, Activities and
Excursions)
I/We, understand there
are dangers and hazards inherent in classes, activities, field trips
and during transportation from Waikiki Community Center to outside
activities and return, do agree to assume all risks and
responsibilities surrounding my/our participation in such
activities, including (without limitation) starting from the date of
my membership. I/We are
healthy and fit to participate in these
activities.
I/We also agree to
assume all risks and responsibilities surrounding my/our
participation in any activities undertaken, as an adjunct
thereto. Further, I/we,
do for myself/ourselves, my/our heirs and personal representative(s)
hereby agree to INDEMNIFY, DEFEND, HOLD HARMLESS, RELEASE and
FOREVER DISCHARGE WAIKIKI COMMUNITYCENTER, a non-profit corporation,
and all its officers, agents, employees and instructors from and
against, any and all claims, costs, attorney fees, liabilities,
demands and actions, or causes of action; or any kind by nature, on
account of damage to personal property, personal injury or death,
which may result from participation from such activities, without
regard to the fault or negligence, if any, of WAIKIKI COMMUNITY
CENTER, its officers, agents, employees, and instructors, during
my/our participation in such activities.
IN WITNESS WHEREOFF,
I/We having read this document and full understand its contents and
consequences have caused this RELEASE to be executed this ____ day
of _____________, _______.
_______________________
________________________________________
________________
Print Name of
Applicant
Signature of Applicant
Date
PERMISSION FOR PRESS
RELEASE
Occasionally,
WAIKIKI
COMMUNITY
CENTER has photos of its
members, and WAIKIKI
COMMUNITY
CENTER will use these photos
for publicity (television, newspaper, magazine, publications,
brochures, newsletters, etc.).
In that situation, it is the policy of
WAIKIKI
COMMUNITY
CENTER to have permission
before using the photos.
I/We hereby give my/our
permission to have WAIKIKI
COMMUNITY
CENTER use my/our photo or
voice for press publication without
compensation.
_____________________
________________________________________
___________________
Print Name of
Applicant
Signature of Applicant
Date
PARENTS/GUARDIANS
CONSENT
I/We are the parents
and/or legal guardians of the minor applicant named. I/We have read, understood
and agreed to the RELEASE, and I/We hereby consent to the
participation of the child in WCC activities.
____________________ ______________________________
_________________
_______
Name of
Parent/Guardians
Signature of Parent/Guardian
Relationship
Date
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