*NEW* KCSR Application July 2016 – December 2016

Membership Application Form


July 1 2016-Dec 31 2016


Membership Dues: $25 for 6 months

Checks made payable to Kane County Senior Resources

Include agency/organization name in the memo section.


Please note: In order to be listed in the 2016 Directory,

Application and dues must be received in the PO Box no

later than July 1, 2016



The annual membership dues will support the following:

o Publication & distribution of a membership directory

o Publication of your contact information on the website

o Discount for the annual Kane County Senior Fair if held

o Monthly professional education program and networking

o Monthly summary of meetings via web page

o Networking events in addition to the monthly meeting

o Annual Legislative Forum


COMPLETE application form; INCLUDE a check payable to Kane County Senior Resources

AND the agency/organization name placed in the memo section.

PLEASE attach a business card and mail to:

KCSR Membership

P.O. Box 616

Geneva, IL 60134



Agency / Organization (Business Name):_____________________________________

(Note: Membership Dues will cover up to 2 individuals from each organization)

Representative #1 Title:______________________________________________________


Cell phone:_____________________________________________________

Representative #2 Title:__________________________________________________________


Cell phone:___________________________________________________

Business Website:______________________________________________________

Business Street Address:_________________________________________________

Business City, State & Zip Code:___________________________________________

Business Telephone Number/Fax:____________________________________________

Industry Category: (Please check all that apply)

Adult Day Care ______

Behavioral Health/Psychological Services _______

Community / Social Services /Senior Services _______

Consultation/Referral Services ______

Financial/Insurance/Realty _________


In Home Care:

Home Care (private duty non medical)_________

Home Care (private duty medical)_________

Home Health (skilled/medical)___________

Hospice_________ Palliative Care________


Home Modifications________

Hospitals ________

Legal Services ________

Outpatient Services /Outpatient Rehab___________

Products / Supplies______

Professional Services______

Senior Residential Facilities/Communities:

Assisted Living ____

Independent Living____

Memory Care____

Skilled Nursing____

Supportive Living_____

PLEASE INCLUDE A BRIEF DESCRIPTION OF YOUR BUSINESS- for use in directory (MAXIMUM OF 50 WORDS- (subject to editing)_______________________________________________________________



REMEMBER: Checks should be made payable to Kane County Senior Resources

AND the agency/organization name placed in the memo section.

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