Senior Studies Institute (SSI)

Portland Community College

Membership Form

Annual membership dues:  $50/individual; $80/two in same household

Complete the form below   and mail with a   check   payable to PCC   (in   the appropriate amount) to the SSI address below. Note:   Only checks payable to PCC are accepted .

□ Check if you DO NOT  wish your name and contact information (email address and phone number only) published in our annual Membership Roster - for SSI related business and distribution to members only.

□ Check if you DO NOT   wish your photograph to appear in SSI publications .

□ Check if you are donating in additional to your membership dues.

□ Check if you are requesting financial assistance for membership dues.

PLEASE PRINT CLEARLY or affix a return address label

Name(s):________________________________________________________________________________

Mailing Address:__________________________________________________________________________

                 

City:______________________________________________ State:________ Zip:_____________________

Contact Phone: Cell?____(Include area code)___________________________________________________

Email: __________________________________________________________________________________

First name(s) for name tag(s):______________________________________________  New Member?: ____

If new member, how did you hear about SSI: ____________________________________________________

SSI thrives with everyone’s participation!  Check all applicable interests. Please use the reverse side for additional comments.

                Presenting/Co-Presenting Class                        Serve on a committee

                Moderate, Facilitate, Provide Zoom Support                 Provide Special Event Assistance

                Serve in an Organizational position                         Other: _________________________

                Coordinate In Person Activities                            _______________________________        

MAIL TO:  SSI,   P.O. Box 80744, Portland, OR 97280-1744         

Revised 7/20/2026