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.
