Membership Form

By signing this form you have consented to the use of this personal information by Active Adult Centre of Mississauga. The Active Adult Centre of Mississauga utilizes reasonable and appropriate physical, technical and administrative procedures to safeguard the information we collect and process. Electronic information is cloud based and managed by a trusted third- party service provider. The information herein will be used to maintain an accurate membership database for the purposes of determining membership eligibility, mailing or emailing information regarding Active Adult Centre of Mississauga activities, sending email alerts, mailing or emailing print newsletters and brochures, requests for donations to the Active Adult Centre of Mississauga, to distribute tax receipts, to ensure donor recognition, to conduct internal surveys or focus groups, and to provide members notification of meetings.

Your information will not be shared on any basis with other organizations. Members and donors have the option to decline the use of their personal information. If you wish to be removed from our list, please contact us at 905 615-3207 to rescind your consent for use of this information.

Active Adult Centre of Mississauga does not trade or sell personal information about members or donors. To review our privacy policy you may visit our website at This information is collected under Ontario’s Freedom of Information and Protection of Privacy Act 39(1) and Section 65.1. Active Adult Centre of Mississauga Charitable Registration. ( # 81959 5893 RR0001).

Please note that all policies, procedures, regulations, restrictions and privileges of Square One Older Adult Centre will apply, despite any name change to the organization in 2018. In addition, your signature on this document implies that you accept responsibility for your own medical coverage, give permission for staff and volunteers of the Active Adult Centre of Mississauga to arrange for any emergency medical care, including hospitalization and transportation if necessary, and agree to pay for all expenses and costs incurred thereby. If emergency medical care is required, all attempts will be made to contact emergency contact person(s) shown above. I agree to release, indemnify and save harmless the City of Mississauga, Hillmond Investments Limited and the staff and volunteers of the Active Adult Centre of Mississauga from all claims arising from participation in any program, activity, event, or trip organized by the staff and/or volunteer at Active Adult Centre of Mississauga by any cause whatsoever.

Your signature also implies compliance with the Active Adult Centre of Mississauga Code of Conduct and the Active Adult Centre of Mississauga Accessible Customer Service Standard.

I also hereby give my permission for images of myself captured during regular and special Centre activities through video, photo and digital camera to be used solely for the purposes of Active Adult Centre of Mississauga promotional material, publications, and social media and I waive any rights of compensation or ownership thereto.
NOTE: Please inform the Centre of changes to address or phone numbers. There is a minimum fee each time a member attends an Active Adult Centre program


Please complete the form below

Part A
Name *
Address *
Phone *
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Part B
Please check the activities that interest you... *