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Membership Form

Membership Form

Thank you for your interest in the City of San Antonio’s Senior Services Program. Whether you are interested in joining us for a midday meal, group exercise, a computer class or to meet up with a friend, we welcome you! To enroll, please complete the form below and allow 2-3 business days for your application to be processed.

Highlighted fields containing an asterisk * are required.


01/31/2023
 
Location *

Member Information Step 1 of 6








Male Female

















Eligibility Step 2 of 6










Low
Middle
High




Yes No

Hispanic or Latino
Not Hispanic or Latino


Volunteer Step 3 of 6


Yes No
*

Nutrition Step 4 of 6

Please complete the Nutritional Risk Assessment below. If your response to the statement is "Yes," select the box that corresponds to that statement.


Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Other Step 5 of 6

*
Yes No
*
Yes No

Agreement Step 6 of 6

To complete your enrollment at a City operated senior center and/or a Nutrition Program partner site, please view and select "yes" to confirm that you have received information regarding member eligibility, senior center policy and rules of conduct, senior services grievance and complaint procedures, client rights and responsibilities and release of information; and that you agree to the terms of the policies listed.


* Yes No     View
* Yes No     View
* Yes No     View
* Yes No     View
Disclaimer: My electronic signature below attests that I am the person represented in this application, that the information contained herein is true and accurate to the best of my knowledge, and serves as my consent to apply for services through AACOG and the City of San Antonio. I understand that my information may be shared to effectively plan, arrange, and deliver services to meet individual client needs. I have read, understand and agree to the terms of the Attachments herein.

        Acceptance of all terms and policies: *
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