The FriendShip -- Member Application
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Before filling out this form, please note Membership Limitations
The FriendShip is not able to provide medical or personal care services, wheelchair transportation, services to those who live in a designated senior residence, or services to those with dementia.
Preferred Title
(not required)
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First Name *
Middle Name or Initial
Last Name *
Preferred Name
Gender
(select one)
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Birthdate *
(Note the calendar tool to the right of the date.)
MM
/
DD
/
YYYY
Retired?
(select one)
Living Status
(select one)
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Pets
(select if applicable)
Contact Information
Residence Address *
(be sure to include apartment number/letter somewhere, if applicable)
Street Address 2
(if needed)
City *
Zip Code *
(5 digits)
Mailing address if different from residence:
Home Phone *
example: 803-602-6434
Cell Phone
example: 803-602-6434
Work Phone
example: 803-602-6434
Email Address
Health
How would you describe your health?
(select one)
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Special Considerations
(Select all that apply.)
Additional Contact Information
Emergency Contact 1 *
Include Full Name - Relationship - Phone Number - Address
Emergency Contact 2 *
Include Full Name - Relationship - Phone Number - Address
Primary Care Physician
Include Full Name - Name of Medical Practice - Phone Number - Address
How did you learn about The FriendShip?
Would you be willing to be a Volunteer to assist other Members?
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Membership Types:
FULL MEMBERSHIP - - - - - - -
1 YEAR
 $600  - Individual
 $900  - Household (2 people)

ASSOCIATE MEMBERSHIP  - - - - - - -
1 YEAR
 $120  - Individual
 $180  - Household (2 people)

I would like to join The Friendship as a . . . .
(Note: You can change your mind later, before paying a fee.)
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Choose type of Full Membership, if applicable.
(Note: You can change your mind later, before paying a fee.)
Choose type of Associate Membership, if applicable.
(Note: You can change your mind later, before paying a fee.)
Primary Name on Membership *
(Enter Member's Name or Primary Member's Name.)
Secondary Name if Household Membership
(if applicable)
Comments or questions:
The FriendShip
2827 Wheat Street
Columbia, South Carolina  29205

Phone: 803-602-6434
Website: www.thefriendship.org
E-mail: contact@thefriendship.org
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