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2. 
4. Jenks Senior Citizens, Inc.
   PO Box 253
   211 N Elm St Jenks, OK 74037
   918-299-1700
6. Last Name*
7. First Name*
9. Address*
11. City*
12. Zip Code*
14. Birthdate*
16. Home Number*
17. Cell Number*
19. Email Address*
21. Emergency Contact #1*
23. Phone Number*
24. Relationship*
26. Emergency Contact #2*
28. Phone Number*
29. Relationship*
31. Annual dues of $
32. Date Joined
33. Secretary
35. Coordinator Information

    1. Birthday Calendar
    2. Name Tag

    1. Art Class
    2. Bridge

    1. Directory
37. In consideration of the City of Jenks, Jenks Public Works Authority, and/or Jenks Aquarium Authority allowing me, and/or the below listed organizations' access to property owned by any or all of the above listed entities, I do hereby for myself, my heirs and assigns, or as authorized on behalf of my organization, as specified below, AGREE to release and hold the City of Jenks, Jenks Public Works Authority, and/or Jenks Aquarium Authority, its officers or employees harmless for any and all claims which I may have now or in the future resulting from access to City property, the condition of the City property and entry upon City property. I understand that I, and/or the organization listed below, assume all risks in association with the access to City property.
    Representing the following organization(s)
    City of Jenks
    Jenks Senior Citizens, Inc.
39. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
41. Electronic Signature
43. Rev. 01/09/19
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45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

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