Become a Member - Registration

Complete application, make checks payable to: Senior Service Coalition of Lake County and mail to:

David Eggering, 888 E Belvidere Rd., Suite 302 Grayslake, IL 60030

Required information is marked by an asterisk (*)

Agency/Organization:
Street Address:
City, State Zip:
E-mail: *
Phone:
Fax:
Contact Person:
Title:
Type of Membership:: New Member; Renewal
Categories:: Adult Day Services; Assisted Living; Continuing Care Retirement Rehab Center Community (CCRC); Financial Services; Funeral Services; Geriatric Care Management; Home Health Care; Hospitals; Independent Living; In-Home Care; Medical Supply Company; Memory Care Facility; Rehab Center; Senior Center; Senior Clubs; Senior Services; Skilled Nursing; Social Service Agency; Supportive Living Facilities
Membership Fee:: Individual ($15.00); Agency / Organization ($25.00); Sponsor ($50.00); Scholarships available for those needing assistance with fees.
Message:
Comments: