Online Virtual Day Program Application

Member Name

First Name Last Name Nickname

Member Address

Street Address

Street Address Line 2

City State

Zip Code

What county do you reside in?

Member E-mail

example@example.com

Member Phone Number

Member Date of Birth

Would you be interested in in-person membership at our Asheville or Huntersville locations in the future?

Yes No Not Sure

Do you have a family caregiver or professional caregiver assisting you?

Yes No

What agency is the professional caregiver from?

Name of caregiver?

Relationship to the member:

Caregiver Address

Street Address

Street Address Line 2

City State

Zip Code

Caregiver E-mail

example@example.com

Caregiver Phone Number

Will this caregiver be available during virtual programming to assist the member if needed?

Yes No

If not, please provide the contact information for at least one person who will be available to assist the member during virtual programming: First Name Last Name
Area Code Phone Number Email Relationship to Member

Do you have a legal guardian? If "yes" please have your legal guardian complete the information below:

Yes No

Name of Legal Guardian?

Legal Guardian Address

Street Address

Street Address Line 2

City State

Zip Code

Legal Guardian E-mail

example@example.com

Legal Guardian Phone Number

Who can Hinds' Feet Farm contact in case of an emergency?

First Name Last Name Relationship to Application

Home Phone Work Phone Cell Phone

Please upload a recent photo of yourself.

Online Media Consent Form

(must be signed by member or their legal guardian as applicable)

I authorize HFF, its assigns and transferees to copyright, use and publish this information about me in print and/or electronically. I agree that HFF may use such information about me with or without my name and for any lawful purpose, including but not limited to such purposes as publicity, illustration, advertising, social media, and Web content. This consent also includes the right to make such changes, fictionalizations and/or creative choices as HFF may decide in its sole discretion. I agree not to bring any action or claim(s) against HFF and its governing board, directors, officers, employees, volunteers, and/or agents now or in the future based on the use and depiction of my information. I understand that I may revoke this release in writing if I wish for my information to be excluded from future media uses. I understand that I cannot revoke a release of my information for which I have given prior consent for media that is already existing and/or published.

I grant Hinds' Feet Farm the right to use my - (please check all that apply)

Name Photograph Video Image Voice Biography History Artwork None

Online Consent Form

(must be signed by member or their legal guardian as applicable)

I am 18 years old or older and a resident of North Carolina.
I have a traumatic or acquired brain injury.
Hinds’ Feet Farm has permission to contact and share my information with the emergency contact person I have provided as well as my caregiver as needed.
I agree to participate in virtual programming using the Zoom platform, which is not considered to be a secure or confidential online platform. I understand that virtual programming may be recorded.
I understand that physical activity, by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries, and I hereby assert that my participation is voluntary and that I knowingly assume all risks . Hinds’ Feet Farm’s virtual programs provide physical activities including but not limited to yoga, line dancing, stretching, and various group exercise classes, etc. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains; 2) major injuries such as eye injury, back injury, heart attacks, and concussions; and 3) catastrophic injuries including paralysis and death. I release Hinds' Feet Farm from any and all liability arising out of my participation in any physical activities and hereby waive my rights herein to assert any action or claim(s) against Hinds' Feet Farm and its governing board, directors, officers, employees, volunteers, community instructors, and/or agents.
I agree to follow the rules of the Hinds’ Feet Farm virtual day program and understand that failure to follow program rules may result in my suspension or expulsion from the program:
- Respect the views and opinions expressed by others in the group.
- No use of illegal drugs, tobacco or alcohol during program activities.
- No cursing or suggestive language.
- Only the enrolled member and a caregiver are allowed in the virtual activity.
- Must be fully dressed at all times.
- May not threaten to harm others.
- Keep information shared by others in the virtual activity confidential.
- Have a contact person for us to reach out to in case of emergency or concerning behavior.
- Hinds’ Feet Farm staff reserve the right to remove you from the virtual activity due to disruptive or threatening behavior.
- Video must be left on at all times while participating in virtual programming.

I will keep all information confidential that is discussed as part of Hinds’ Feet Farm’s programs within a group setting.

Signature

Clear

Virtual Day Program Online Application