• Wellness House Adult Member Application

    Please complete this form in its entirety. The information below will be utilized for data purposes only. This information helps our organization to apply for grants to continue funding our operations.
  • (Ex: "he, him"; "she, her"; "they, them")
  • Preferred Phone Number for Contact
  • If Preferred Phone Number Is Unavailable
  • Emergency Contact Information

  • Additional Information

  • Medical Information

  • Program Waiver Agreement

    Please check each box to show that you acknowledge and understand the following statements.
  • Signature

    Unless otherwise noted, programs are for ages 18 and older.