California Grey Bears

 

 

2710 Chanticleer Avenue
Santa Cruz, CA 95065-1812
(831) 479-1055

Join Grey Bears

 

I am at least 55 years old and live in Santa Cruz County

First Name

Year of Birth

Address

City

Zip

Phone

Grey Bears Membership Fee Schedule

1-Year  $20

2-Years  $35

3-Years  $50

Renew My Membership for :

Please call me regarding membership

I would like to receive a Brown Bag at a site near my home

I do not wish to receive a Brown Bag, but I want to be a member

1-Year  $20

2-Years  $35

3-Years  $50

Lifetime Membership    $200

Lifetime Membership  $200

Application for Membership

am legally blind

have heart/lung condition

walk with difficulty

use wheelchair or walker

Please help us compile aging statistics.  How do you identify yourself?(Please select one of the following)

I am homebound and qualify for shut-in delivery of a Brown Bag because I:

Other

For statistical purposes only, please check appropriate box:

I live alone:  monthly income $1,300 or less (yearly $15,600 or less)

I live with another:  monthly income $1,750 or less (yearly $21,000 or less)

My income is above these amounts.

email

Other

I will pay my dues by credit card (You will be able to make your payment by credit card on the next page after you hit the submit button at the bottom of this  application form)

I will mail my payment or bring a cash payment to the office.

Last Name

African American American Indian Asian/Pacific Isle Caucasian Latino