Membership Application

First Name (required)

Last Name (required)

Email (required)

Phone (required)



Postal Code

Emergency Contact Name

Emergency Contact information

I agree to abide by the 411 Seniors Centre’s Standard of Behaviour, which reads: “The 411 Seniors Centre is committed to providing a meeting place where everyone is safe and is treated with courtesy, dignity and respect. Behaviour which is discriminatory, violent or threatening will not be tolerated.”

I am aware that by providing my e-mail address, it will be added to our mailing list. I will be sent monthly program schedules, AGM notices, and updates.

To prove you're not a robot, please type what you see in the box below...
To use CAPTCHA, you need Really Simple CAPTCHA plugin installed.