New 2017 Membership Application

Membership Application Form

 

January 1, 2017-December 31, 2017

 

Membership Dues: $50 annually ($25 /6 months or less)

Checks made payable to Kane County Senior Resources

Include agency/organization name in the memo section.

 

**TO BE INCLUDED IN THE 2017 PRINTED DIRECTORY

PAID MEMBERSHIP IS DUE NO LATER THAN MARCH 1ST, 2017**

 

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: $50 Membership Dues will cover up to 2 individuals from each organization)

Representative #1 Title:________________________________________________

Email:______________________________________________________

Cell phone:_______________________________________________________

Representative #2 Title:_____________________________________________________

Email:____________________________________________________

Cell phone:______________________________________________________

Business Website:_________________________________________________

Business Street Address:___________________________________________

Business City, State, ZipCode:_____________________________________________

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 SERVICES TO BE INCLUDED IN THE DIRECTORY (50 WORDS OR LESS-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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