Skip to Main Content

Create an Account - Increase your productivity, customize your experience, and engage in information you care about.

Sign In

Vimeo

Search

Home
My Account
Printer Friendly
Email Page
Contact Us
RSS
Site Map
Translate Page
Notifications
Documents

Facebook
Twitter
Pinterest
Delicious
Blogger
LinkedIn

Government
Departments
Public Safety
Community
How Do I…

Home
Form Center

Form Center Module

Form Center

Search Forms:

Search Forms Select a Category

All Categories
Agawam Family Challenge
Americans With Disabilities Act (ADA)

Assessor's Office
Citizen Requests
Contact Us

Fire Department
S-5 Form
Senior Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Sign in to Save Progress

New "Membership" Form

This form has been modified since it was saved. Please review all fields before submitting.

Steps

1. Personal and Contact Information This section is complete This section is incomplete
2. Housing Information This section is complete This section is incomplete
3. Emergency Information This section is complete This section is incomplete
4. Mailing List Survey This section is complete This section is incomplete

Personal and Contact Information

First Name*
Middle Initial
Last Name*
Nickname (Alias)
How would most people know you?
Gender*
Birthdate*
Birthdate
Physical Address*
Mailing Address (If different from Physical)
City*
State*
Zip Code*
Primary Phone Number*
Secondary Phone Number
Primary Phone Number is:
1. Home Phone
2. Cell Phone
3. Work Phone
Secondary Phone Number is:
1. Home Phone
2. Cell Phone
3. Work Phone
Ethnicity*
Ethincity (Other):
Email Address
Continue

Housing Information

Are you the head of house?*
Do you live alone?*
Do you live in a rural area?*
Residence Type*
Continue |Go Back

Emergency Information

Emergency Contact First Name*
Emergency Contact Last Name*
E-Contact Primary Phone*
E-Contact Secondary Phone
E-Contact Relation to You*
Primary Phone is:*
1. Home Phone
2. Cell Phone
3. Work Phone
Secondary Phone is:
1. Home Phone
2. Cell Phone
3. Work Phone
Second Emergency Contact
Emergency Contact First Name
Emergency Contact Last Name
E-Contact Primary Phone
E-Contact Secondary Number
E-Contact Relation to You
Primary Phone is:
1. Home Phone
2. Cell Phone
3. Work Phone
Secondary Phone is:
1. Home Phone
2. Cell Phone
3. Work Phone
Do you have any disabilities?*
Please note: If you answer "Yes" to this question, a staff person will follow up with you for more information.
1. Yes
2. No
Do you have any allergies?
Please note: If you answer "Yes" to this question, a staff person will follow up with you for more information.
1. Yes
2. No
Continue |Go Back

Mailing List Survey

Would you be interested in receiving a monthly newsletter by mail if it were at no cost to you?
1. Yes
2. No
Would you be interested in a newsletter mailing if it were for the cost of postage (approximately $6 per year)?
1. Yes
2. No
Do you currently subscribe to our newsletter via email?
1. Yes
2. No
3. Please send me the link to subscribe

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
Submit Submit and Print | Go Back

* indicates a required field

Agendas & Minutes

Online Payments

Financial Reports

Contact Us

36 Main Street
Agawam, MA 01001
Phone: 413-786-0400
Email Us

Using This Site

Home
Accessibility
Privacy
Copyright Notices
Contact Us
Government Websites by CivicPlus®

/QuickLinks.aspx

[]