SSAFE New Member Sign-Up Form

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MEMBER SIGN UP FORM

JOIN SSAFE

First Name *

Last Name *

Email *

We do not share or sell your email or contact information. You are SAFE with SSAFE!

Senior Living Community *

Enter the senior living community where you reside or work. If none, enter "None"

Street Address *

Unit Number or Other

City *

State/Province *

Zip/Postal Code *

Country *

Best Phone Number *

(Optional) Select as many items as you like; elaborate below if you wish:

Help organize on-campus events

Promote resident participation in SSAFE activities

Participate in hands-on direct activities on campus

Work on fundraising initiatives

Rally support for federal, state, and local advocacy issues

Assist behind the scenes with administrative support

Research, gather, and analyze information and data

Monitor a SSAFE Listserv

Your selections will be used for discussion as we welcome you to SSAFE. By selecting your areas of interest above, you are not making a commitment.

(Optional) Who referred you to SSAFE?

Optional

(Optional) Staff at a senior living community: Please enter your job title.

For staff members only.

(Optional) Your notes to us:

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Senior Stewards Acting For the Environment - www.SSAFE.org - info@ssafe.org