Senior Shore Waitlist Application Senior Housing Waitlist Application Name(Required) First Last Other SurnamesMarital Status Married Widowed Single Divorced Separated Unmarried & Living Together Gender Male Female Non-Binary Prefer Not to Say Drivers License #Drivers License StateSocial Security #Mailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Do you have a different physical address?(Required) Yes No Physical Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email Would you like to receive our newsletter via email?(Required) Yes No Birthdate(Required) MM slash DD slash YYYY Addt'l Birthdate MM slash DD slash YYYY Ethnicity African American/Black Asian AK Native/American Indian Hispanic Native Hawaiian/Pacific Islander Caucasian/White Other Decline Membership Options(Required) Annual Membership (Single) Lifetime Membership (Single) Lifetime Membership (Couple) Total Payment Method