Full Name (If a couple, list both names) *


Street Address *


City, State, ZIP *


Email Address (We never share our email list.) *


Reenter Email Address *


Phone *


Cellphone (optional)


Gender (choose one) *
Female
Male

Year of Birth (optional but helpful for planning and grants)


I have lived in Laguna Beach for... (choose one) *
Less than 5 years
5-10 years
10-20 years
20-30 years
More than 30 years
I live outside Laguna

I live ... (choose one) *
alone.
with a spouse, friend, or family.

Would you like to become a Contributing Member? (Choose one) *
Yes! I will use the Google Donate button to make a tax-dedictible donation of $25 or more.
Yes! I will make a donation when I am at the Susi Q.
Yes! I am mailing a donation to Laguna Beach Seniors, 380 Third Street, Laguna Beach CA 92651
I cannot become a Contributing Member at this time.

We appreciate your comments and suggestions.