Champion for the Aging Membership Form Name * First Name Last Name Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Example: 000-000-0000 (###) ### #### Email * Select a Membership Plan: * Annual Membership - $600 per year Recurring Monthly Membership - $50 per month Monthly Recurring Start Date MM DD YYYY Payment Method: * Credit Card Debit Card Check Other Credit Card Number / Debit Card Number * Expiration Date: * CVV * How did you hear about us? Social Media Website Event Referral Other Please select your primary area of interest: Volunteer Opportunities Events and Activities Adopting a Senior Other Message Consent: Your Electronic Signature - (First Name & Last Name) is Required Below * I agree to receive updates, newsletters, and other communications from ElderServe. I understand that my membership is non-refundable and that the benefits are subject to change. Thank you for your support and welcome to the Champion for the Aging Membership Program!Once your registration is processed, you will receive a confirmation email with details about your membership benefits and any upcoming events.Keep an eye on your email for monthly updates, invitations, and/or important information. We’re excited to have you join us in supporting and empowering seniors in our community!
