Membership request for Senior Citizen Council of Cobb County
First Name*
Last Name*
Spouses Name
Spouses Last Name
Address *
Address 2
Zip Code
Phone Number
Spouse Email
I would prefer to be contacted byPhone   Email   
Membership Subscription*Individual Membership including Bulletin Subscription $ 12.00  Membership and Spouse including Bulletin Subscription $ 15.00 
Sponsor including Bulletin Subscription and one quarter page ad $ 70.00 
Family Membership includes 1 Year Bulletin Subscription, 1 Vote and 1 Trip Discount per person $ 12.00   
Each additional member up to 3. $ 5.00   
Date of Birth
How did you hear of the Senior Council
Are you planning to join SeniorsGO?Yes   
Is this a renewal membership?*Yes   No   
Are you interested in learning more or becoming more involved in the following activities: