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Membership Application 2009 Office use only:

2009 Membership $90.00 (circle) New—Renewal $________


Or if paid by 12/31/08 $80.00 (circle) Check—Cash—Credit Card
Application Fee for new members & Receipt
 renewals after March 1 $25.00 #____________________Date___________
 Amount Due $__________
 etap______________ SC ___________

Please check one:


__Bordeaux __College Grove __Donelson
Name ______________________________________________________________
__Knowles __Martin __Madison
(First) (Middle) (Last)

Address ______________________________________County________________
Married_____ Widowed___
City ______________________________State: ___________Zip: ______________ Single _____ Divorced ___
Race_______ Sex_________
Phone ___________________ __________________ _____________________ Number in household________
(Home) (Work) (Cell phone)
Check all that apply:
E-Mail Address (please print)____________________________________________ *required by federal/state funding agencies
____I live alone.
Is Spouse a member ___ If yes, please give his/her full name _________________
____I have 2 or more health conditions
Social Security # last 4 digits please:____________ Birth Date _____/_____/_____ monitored by a physician.
____I am eligible to receive public
In Case of Emergency, notify ______________________ Relationship___________ assistance.
____I have limited English language
Emergency _________________ ___________________ ___________________ skills.
(Day phone) (Evening phone) (Cell phone) ____I am unable to drive.
____I have a disability,
Your physician________________________ Physician Phone ________________ (describe)______________________.
Information required by federal/state funding agencies:
_____ GRIEVANCE PROCEDURE
Is your income at/below $850.83/ Single per month ___ yes ___ no By my initials, I understand that if I have a
$1,140.83/ Couple per month ___ yes ___ no serious complaint about not receiving
Is your income at/below $1,701.67/ Single per month ___ yes ___ no adequate service from FiftyForward, I have
the right to complain to the proper
$2,280.00/ Couple per month ___ yes ___ no authorities with no penalty to me. A copy of
the Grievance Policy will be made
available upon request.
Signature _________________________________Date _______________
RELEASE OF INFORMATION FOR STATISTICAL REPORTING
I understand that the information collected will not be identified with me personally. It may be used in statistical reports. I give my
permission to use the information for statistical reporting.

REQUEST FOR INTERAGENCY INFORMATION SHARING


I receive services from more than one program funded through the Tennessee Commission on Aging and the Area Agency on Aging. I request
the information from my assessment be shared with the agencies listed below that would otherwise have to interview me again to collect the
same data.

AUTHORIZATION FOR REFERRAL FOR SERVICES


I give my permission for FiftyForward to contact the agencies or persons listed below and to release only such information as may be needed to
determine the level and types of services that I may need. I also grant permission to the receiving agencies to report back regarding services that
I may/may not receive and/or any additional information that may significantly reflect on my need for services. Please initial to give
authorization.
Information will be shared with the following agencies. (If this section does not apply, write none.)

Agency ________ Purpose ________

Volunteer Opportunities at Knowles


An added benefit of Knowles membership is a wide variety of volunteer activities. Some ways you can participate:

Join the Knowles Advisory Council


Join the Membership Committee
Join the Lifelong Learning Advisory Council
Start a special interest group (e.g. quilters, book group, veterans, handbells, garden club)
Help with special events and fundraisers such as Mature & Magnificent, Threadfest, Week of Celebrations
Stuff envelopes, Give tours, Drive the van
And Much More!

To Charge by Credit Card: Name_________________________________________________(as it appears on the card; please print)

____Visa ______MasterCard Card Number: _______________________________________ Expiration Date: ____________