MEMBERSHIP APPLICATION

Name*

First

Last

Email*

Date of Birth*

Home Number*

Mobile Number*

Spouse Name:

First

Last

Address*

Street Address City State / Province / Region Postal / Zip Code

Emergency Contact Name*

First

Last

Emergency Contact Phone Number*

Doctor's Name:*

Doctor's Phone Number:*

Medical Alerts:

Diabetic

High Blood Pressure

Allergies

Other Medical Problems:

Do you have medication to take in case of emergency? List:

911 will be called for all emergencies

PICKENS SENIOR CENTER CODE OF CONDUCT

Purpose
The Pickens Senior Center (hereafter Center) is committed to providing a safe, welcoming environment for the members visitors and staff of the Center. The Board of Directors (hereafter the Board) has adopted the following Code of Conduct to ensure a respectful, supportive, relaxed and pleasurable environment for all. The goal of this Code of Conduct is to maintain a warm, positive atmosphere.

Violations
Violations of the Code of Conduct include, but are not limited to the following:
• Loud, disruptive, obscene, hateful or abusive language or behavior which is disturbing to members and/or staff.
• Making threats or demonstrating threatening behavior in words, writing or actions toward members, guests and/or staff.
• Inconsiderate or discourteous language or behavior toward members and/or staff.
• Violation of any federal, state, county of city law or ordinance while on Center property or engaging in Center activities.
• Damaging Center materials, equipment, furniture or grounds.
• Other conduct that is deemed inappropriate by the Board.

Consequences of Conduct Policy Violations.

Each violation will be reviewed by the board individually with appropriate action being taken. Violations of this policy may result in the following actions:
• Verbal warning
• Suspension of membership
• Revocation of membership

I have read and understand the Pickens Senior Center Code of Conduct Policy.*

Yes