Membership Form

All members have a choice of either Standard or Prime membership.

Standard Membership: $216/year for Individual; $384/year for Household*

Prime Membership: $588/year for Individual; $1,056/year for Household*

*a household is defined as any two individuals living at the same mailing address with one member aged 50 or better.

If you would prefer to pay your annual membership on a monthly basis, please contact Suzanne Orejuela, Member and Visitor Services Coordinator, at 434.220.9732 or via email.

Healthy Aging for All: Everyone should have the opportunities that aging brings. In our work to extend healthy life expectancy and quality of life for everyone, The Center is committed to creating an environment that is welcoming, just, equitable, and inclusive, without biases or discrimination based on differences of any kind. Because the only healthy environment is one that reflects and respects the rich diversity of the communities we serve.

After you complete your registration form, please stop by the Welcome Desk to receive your membership key tag and a warm welcome!

Member Information

Title (Mr./Mrs./Ms.)

First Name

Nickname (if preferred)

Last Name

Address (Street Name and Number)

City

State/Province

Zip/Postal Code

Home Phone

Cell Phone

Birthdate (mm/dd/yyyy)

Other Member (Households only)

Emergency Contact Information

Emergency Contact Name

Relationship

Phone Number

Demographic Data - Important for grant funding and reporting

How did you hear about us?

Residence

Ethnicity

Race

Gender Identity

Transportation to/from Center

Release and Waivers

Release and Waiver of All Claims
FOR AND IN CONSIDERATION OF my participation in the Senior Center, Inc. programs and activities, I forever release and covenant to hold harmless the Senior Center, Inc. and its officials, officers, employees, independent contractors, representatives and agents from any and all claims or causes of action for injuries, costs or other damages which I may hereafter have as a result of my participation in any Senior Center, Inc. program or activity. I expressly agree that this Release and Waiver is as broad and inclusive as permitted by the laws of the Commonwealth of Virginia and that if any portion is invalid, I agree that the balance shall continue in full force and legal effect.

Code of Conduct
To ensure the safety and enjoyment of all, The Center has a Code of Conduct by which all members and participants must abide. The code is posted on the membership bulletin board. A copy is available from the Member & Guest Relations Coordinator.

Information Release
I hereby authorize my name, address, phone number and/or email address to
be made available to those Center members who request to contact me.

Picture Release
Senior Center, Inc. has permission to use my photograph, video and audio recordings, likeness, artwork, profile and/or story in any publications, web pages, and other promotional materials produced, used by, and representing Senior Center, Inc., including, but not limited to: newsletters; annual reports; brochures; email; DVD, and website. I understand the circulation of the materials could be worldwide and that there will be no compensation to me for this use.

Privacy Policy

We keep your personal information private and secure. When you make a payment through our site, you provide your name, contact information, payment information, and additional information related to your transaction. We use this information to process your payment and to ensure your payment is correctly credited to your account.

Contact Us

Senior Center, Inc. •• 540 Belvedere Blvd., Charlottesville, VA 22901 •• (434) 974-7756 •• https://thecentercville.org