MEMBERSHIP APPLICATION FORM

310 Paoakalani Avenue Ÿ Honolulu, HI 96815 Ÿ Phone: (808) 923-1802 Ÿ Fax: (808) 922-2099

E-mail: joan@waikikicommunitycenter.org  Ÿ Website www.waikikicommunitycenter.org

Last Name: ___________________ First Name: ______________ Date: ___________

Birthdate: __________ E-mail: _____________________ Local Phone_____________

2^nd Member Name: _______________________________ 2^nd 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

What is the main reason you joined today?______________________________________________________________

Please check one category:                                                                         Per Year           6 Months

____  INDIVIDUAL (54 and younger) .……………………………………………  $ 35.00                $ 25.00

____  OHANA (Couples, parents and Guardians) ………………………………  $ 55.00               $ 45.00

­­­­____  SENIOR INDIVIDUAL (55 and older) …………………………………… .. $ 30.00              $ 20.00

____  SENIOR OHANA (Couples, parents and Guardians)……………………  $ 40.00              $ 30.00

____  Please join and support WAIKIKI COMMUNITYCENTER with a donation.

          ___ $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:                                  

____  Senior Citizen Programs                                                   ____  Childcare Programs

____  Classes _____________                                                    ____  Community Activities

____  Volunteer Activities                                                           ____  Computer Classes

____  Programs ____________                                                   ____  Meeting new people

____  Health/Wellness Programs                                                ____  Travel/Excursions

How did you hear about WCC?  Word of mouth - Friends  Media  Newspaper   Who?______________

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 2^nd address? __Yes

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+)

Are you over 60 years of age?  Yes/No

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!