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Senior Shipshewana Trip Registration

  1. Seniors Shipshewana Trip Registration 

  2. Please include hyphens.

  3. Must be 62 years of age or older, to quantify as a Senior.

  4. We provide one of the following:

    •Valid State ID or Drivers license

    •Rental or Lease Agreement

    •Current Utility Bill

  5. Any known allergies

  6. Assistance with walking, driving or bathroom?*

    Please select which one applies to you. 

  7. Emergency Contact Information

  8. Please include hyphens.

  9. Please include hyphens.

  10. Relationship to Member*
  11. Digital Signature*
  12. Leave This Blank:

  13. This field is not part of the form submission.