Kensington Club@Home Application for Care Partner

Care Partner Name

First NameLast Name

KC Member/Applicant Name

First NameLast Name

Care Partner Email 1 for Club Correspondance

example@example.com

Care Partner Email 2 for Club Correspondance

example@example.com

Care Partner 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Care Partner 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Care Partner 1 Best Phone Number to Reach You

Area CodePhone Number

Care Partner 2 Best Phone Number to Reach You

Area CodePhone Number

Care Partner 1 Cell Phone Number if Different

Area CodePhone Number

Care Partner 2 Cell Phone Number if Different

Area CodePhone Number

Do you have a diagnosis?

YesNo

If Yes, what year? blanks

What do you hope to gain from Kensington Club@Home?

Enrichment/Stimulation/Socialization for loved one living with Alzheimer's disease & related dementias (ADRD)?RespiteCare Partner resourcesSupport from other caregiversOther

How did you hear about JCA Kensington Clubs?

Disclosure, Acknowledgement and Release of Claim

By signing up for any JCA Kensington Club sessions, I acknowledge that activities may involve some physical activity which are designed and conducted for an average aged population but may not be appropriate for all members. Caregivers must make an informed judgement and advise staff of any physical impairments of the enrolled member. Activities conducted remotely/virtually requiring monitoring by a caregiver are the sole responsibility of the caregiver and member. Caregiver and member understand and agree that member is capable of participating safely in the sessions and the activities.

Caregiver and member and any guardian for member hereby release, discharge and hold harmless, and indemnify and defend against any claim the Jewish Council for the Aging and Kensington Clubs, along with its directors, officers agents employees, partners, funders and sponsors from any and all liability, claims, and demands of every kind with respect to, including without limitation, any bodily injury, illness, death, or any other physical, mental or emotional or psychological harm, that may arise from participation in the classes.

Member Name

Caregiver 1 Signature

Date of Signature