OLLI Membership Form

OLLI Membership Form Unless otherwise noted, all fields are required.
Member		If applicable, second member (in same household)
First Name		First Name
Last Name		Last Name
Email Address:		Email Address:
Date of Birth	Check if this is a renewal and there are no changes to your contact information.	Date of Birth

Annual Membership Fee
	Full-year Membership (July 1 - June 30) Membership ($125) Second membership, household discount ($100)
OLLI for All Scholarships
	At OLLI, we believe that lifelong learning is for everyone in our community, regardless of ability to pay. Please consider making a donation in support of our OLLI for All Scholarships. Donations are tax-deductible. I would like to donate $


Address
Address
City
State
Zip
Home phone
Cell phone
Emergency contact name
Emergency contact phone

	Gender (not required) Male Female How did you learn about OLLI? Word of mouth Email from OLLI Newspaper Radio Other (Please add other source below) Would you be willing to volunteer in the classroom or to assist with other OLLI activities? Yes No Would you be willing to teach a course or facilitate a group discussion? Yes No Fields of interests (check all that apply) Creative Arts Contemporary Issues Economics and Finance The Environment Government History Literature Philosophy Science Technology Theology Wellness Other