Become a Seniors are Special Member Senior Services Activities Center Become a Seniors are Special Member Apply to become a Seniors are Special member. Last Name(Required)Middle InitialFirst Name(Required)Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email(Required) Phone #Date of Birth(Required) MM slash DD slash YYYY Sex(Required) Male Female Check the type of insurance you have(Required) Medicare Medicare Select Medicare Supplement Major Medical Medicaid CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
