Clone of Returning Participant Registration Form

THE ARC OF SAN DIEGO OUR PLACE WELLNESS CENTER REGISTRATION FOR RETURNING PARTICIPANTS

If you have questions, please contact Justin Umpierre (jumpierre@arc-sd.com) at 619-685-1175, ext. 246.
Agreement of Release & Waiver of Liability
Name *

First Name Last Name
I hereby agree to the following:

1. That I am participating in the Our Place Wellness Center during which I will receive information and instruction about exercise and health. I recognize that the Our Place Wellness Center’s classes require physical exertion that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.

2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Our Place Wellness Center. I represent and warrant that I am physically fit and have no medical condition that would prevent my full participation in the Our Place Wellness Center.

3. In consideration of being permitted to participate in the Our Place Wellness Center, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the Our Place Wellness Center.

4. In further consideration of being permitted to participate in the classes offered by the Our Place Wellness Center, I knowingly, voluntarily and expressly waive any claim I may have against the instructor or The Arc of San Diego for injuries or damages that I may sustain as a result of participating in these classes.

5. I, my heirs, or legal representative of such forever release, waive, discharge and covenant not to sue The Arc of San Diego and its officers, directors, employees, agents, sponsors, in-kind donors or volunteers and any of its Our
Place Wellness Center’s instructors for any injury or death caused by their negligence or other acts.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.
Signature of participant:

Clear
Date

Month Day Year
If participant is under 18 or conserved: - As legal guardian of this participant, I consent to the above terms and conditions:
Signature of guardian/conservator:

Clear
Date

Month Day Year
OUR PLACE WELLNESS CENTER CLASS REGISTRATION

Participants are registered for Our Place classes on a first come, first served basis. Our Place staff will take every effort to match each participant with their preferred class choices. However, some participants may not be enrolled in all top 3 class choices. All classes are 50 minutes in length.
**Please RANK each class in order of preference. 1 = Most Preferred Class; 9 = Least Preferred Class **
Adaptive Yoga - Group class which focuses on improving flexibility and mental strength through bodily postures. *
Adaptive Fitness - Group class which focuses on improving strength through weight lifting and cardiovascular exercise. *
Functional Fitness - Group class which focuses on improving functional movements and range of motion using “every day” items. *
Healthy Cooking - Group class which focuses on improving each participant’s nutritional plan through simple strategies and hands-on cooking classes. *
Art Therapy - Group class which focuses on improving overall well-being through artistic movements and art projects *
Music Therapy - Group class which focuses on improving overall well-being through the power of music and therapeutic movements. *
Adaptive Zumba/Dance Me Fit: Group class which focuses on improving cardiovascular strength through aerobic/dance movements to rhythmic music. *
Adaptive Taekwondo (NEW!) - Group class which focuses on improving flexibility, strength, and stamina through non-combative methods. *
Fit 4 Drums (NEW!)- Group class which focuses on improving the entire body through music and active,aerobic drumming. *
SHIRT SIZE *
LOCATION *
Participant Name *
Nickname *
Email
example@example.com
Name of Parent/Guardian *
(if applicable)
Relationship *
Email
example@example.com
Phone Number *

(3-Digit Area Code) Phone Number
24 HR Emergency Contact *
Name
Relationship *
Primary Phone *

(3-Digit Area Code) Phone Number
Other Phone

Area Code Phone Number
Alternate Responsible Party *
name
Relationship *
Phone *

(3 Digit Area Code) Phone Number
PUBLICITY RELEASE FORM
The Arc of San Diego is making a concentrated effort to promote the positive activities and successful work of our staff and consumers. This includes working with the local newspapers, radio,television stations and other media
publications.

Throughout the year, there will be opportunities for various participants to be interviewed and/or photographed as well as identified by name and program.
Please select an answer below to inform us of your wishes regarding publicity. *

I give permission to be interviewed, identified, and/or photographed/filmed for use by The Arc of San Diego, including unlimited use for any and all purposes deemed appropriate by The Arc in printed, electronic,Internet, and other media without limitations or restrictions, and waive any claims of right to compensation orartistic control relating to the interviews, video footage, or pictures. I request that you do not interview or photograph me.
I have read and/or fully understand the above "Publicity Release" form. In signing this form, I certify that I am in agreement with its intent and purpose.
Name *
Date

Month Day Year
Date
Signature

Clear
Signature of Guardian/Conservator

Clear
**Please note that this consent is updated annually and will be kept on file at The Arc of San Diego. You may revoke consent at any time by notifying The Arc of San Diego staff.
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THE ARC OF SAN DIEGO OUR PLACE WELLNESS CENTER REGISTRATION FOR RETURNING PARTICIPANTS

OUR PLACE WELLNESS CENTER CLASS REGISTRATION

PUBLICITY RELEASE FORM