The Club / Diner Member Application (rev. 07.01.26)

Welcome to Wise & Healthy Aging! We're excited to have you join our community.

To get started, complete this application—we’re here to support you every step of the way. A valid photo ID with address is required for membership and may be uploaded below, or copied at 1527 4th St, Santa Monica. For questions, call 310.394.9871 or email memberservices@wiseandhealthyaging.org.

Question Title

1. Programs (select all that apply) (Required.)

The Club: Lifelong Learning for ages 50+. $25 Membership Fee ($15 for Santa Monica residents)

The Diner: Congregate Meals for ages 60+. Free for Santa Monica Residents.

Question Title

2. Member Info (Required.)

First Name *

Last Name *

Address *

Apartment / Unit #

City *

State/Province *

ZIP/Postal Code *

Cell Phone # *

Email Address *

Home Phone # *

Question Title

3. If the address above is temporary, please fill in a permanent address.

Address

Apartment / Unit #

City

State/Province

ZIP/Postal Code

Question Title

4. Emergency Contact (Required.)

First Name

Last Name

Cell Phone #

Email Address

Relationship, e.g, Spouse, Friend, Neighbor

The Club / Diner Member Application (rev. 07.01.26)

Welcome to Wise & Healthy Aging! We're excited to have you join our community.

Question Title

* 1. Programs (select all that apply) (Required.)

Question Title

* 2. Member Info (Required.)

Question Title

* 3. If the address above is temporary, please fill in a permanent address.

Question Title

* 4. Emergency Contact (Required.)

1. Programs (select all that apply) (Required.)

2. Member Info (Required.)

3. If the address above is temporary, please fill in a permanent address.

4. Emergency Contact (Required.)