MCSSA Membership Application

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Fee: $10.00Annual Dues (April 1 to March 31)
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*First Name
*Last Name
*Street Address
*City
*State
*Zip Code
Email
*Phone
*Emergency Contact Name
*Emergency Contact Phone
DONATION - please support MCSSA's mission to improve the quality of life for seniors through exercise and social interaction.
Enter amount of your donation
$ 
*Please acknowledge by checking the box:
 The participant assumes all risks associated with participation in the above activities. MCSSA assumes no liability for injury or damages arising from participation in these activities. Due to the strenuous nature of some activities, MCSSA encourages each participant to consult his or her physician concerning fitness to participate in the program. The participant consents to emergency treatment. 
If paying by Zelle, send payment to MCSSA-treasurer@usa.net
Total Due:
$ 
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