Jewish Family Service and Children's Center of Clifton-Passaic
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SequoiaSenior Services

Membership Application

Your Name (required)

Address

Phone (required)

Do you have a personal emergency response system?

YesNo

If not, are you interested in obtaining one?


YesNo

Birth Date

Your Email (required)

Referred By

Emergency Contact (Name, Address, Phone)

Medical Issues (ex. Pacemaker, Diabetes)

Doctor (Name & Phone)

Do we have permission to contact in the event of medical emergency?

Membership Type

Submit online application form here or mail downloadable application.

Make check payable to Jewish Family Service and mail to:
Jewish Family Service, 925 Allwood Road, Clifton, NJ 07012

Email for more information to: seniors@jfsclifton.org

The Sequoia Senior Center is located at:
565 Broadway, Passaic, NJ 07055 • Phone: 973-246-7717