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Golden Club Basic Membership Form
Golden Club Basic Membership Form
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Email
*
Name
*
First
Last
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Gender
*
Male
Female
How did you hear about the MaiFS Golden Club?
Which services do you wish to avail from the MaiFS Golden Club?
Attending MaiFS Golden Club events (in-person or virtual)
Getting a Golden Club volunteer assigned to you (This requires Premium Membership, please contact MaiFS Office)
Home visits by Golden Club volunteer (This requires Premium Membership, please contact MaiFS Office)
Ride to go somewhere (This requires additional forms, please contact MaiFS Office)
Other (Please call MaiFS Office to discuss)
Which languages are you proficient in (speaking, reading, writing)?
If you have not mentioned English above, do you need a translator?
Yes
No
Not Applicable
Emergency Contact- Full Name
*
Relationship with the Emergency Contact
*
Emergency Contact- Phone Number
*
Emergency Contact- Address
*
Liability Waiver - Member's Full Name & Date
*
Yes
No
I consent that I shall not hold any member, volunteers and Mai Family Services, responsible for any and all liabilities while attending, participating, or performing in any Golden Club events or activities.
Liability Waiver- Member's Full Name & Date
*
Yes
No
I consent that if an emergency arises during Golden Club event, MaiFS team members will call 911 for assistance. I understand that I will be responsible for any financial charges incurred. I will not hold MaiFS or its members or volunteers responsible for any financial costs.
Eligibility Requirement of MaiFS Golden Club
*
I certify that I am over age 60 and resident of Michigan
Submit
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40 years of MaiFS
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