C.A.E. Adult Participant Registration
Upon completion, a C.A.E. representative will contact you within 1-2 business days.
Registration Type
*
Please Select
Adult Open Gym - $5 Day Pass
Adult Open Gym - $25 Monthly Pass
AARP Digital Literacy 50+
Financial Literacy Workshop
Grief Support Group
Just Move Fitness - $5 Weekly Pass
Just Move Fitness - $15 Monthly Pass
Prep4Work
Recovery Support Group
Other Not Listed
Date
*
-
Month
-
Day
Year
Date
What is the name of the program you are registering for?
Name
*
First Name
Last Name
Suffix
City You Live In
*
Please Select
Carlton
Clark
Clarks Mills
Farrell
Fredonia
Greenville
Grove City
Hadley
Hermitage
Jackson Center
Jamestown
Mercer
Sandy Lake
Sharon
Sharpsville
Sheakleyville
Stoneboro
Transfer
West Middlesex
Wheatland
Other
Other - City You Live In
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Gender
*
Please Select
Male
Female
Non-Binary
Date of Birth
*
-
Month
-
Day
Year
Date
Ethnicity
*
Alaskan
American Indian
Asian
Black/African American
Cuban
Hispanic
Mexican
Puerto Rican
White/Caucasian
I choose not to answer
Select all that applies
Emergency Contact Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Blanket Release Attestation
MEDICAL RELEASE: In the event of an emergency, Community Arts Experience has my permission to contact the local emergency ambulance service, who will proceed as necessary. In case of serious injury or illness, my child can be transported to the nearest Emergency Room where they may proceed with treatment including but not limited to medications, injections, anesthesia, and surgery.
*
I Authorize
I DO NOT Authorize
FOR EMERGENCY TREATMENT: I authorize Community Arts Experience to arrange for transportation in case of an accident or acute illness of the participant. In the event it is not possible to receive instruction for the participant’s care, consent is given to any licensed physician for treatment. I allow the physician to administer medication and to perform necessary treatment for the preservation of the participant’s health and well-being. I understand that any cost incurred for the treatment of sudden illness or accident shall be paid by me. This authorization and consent for treatment are given to Community Arts Experience in conjunction with any authorized event.
*
I Authorize
I DO NOT Authorize
GENERAL RELEASE OF LIABILITY: In consideration of being allowed participant privileges in any program of Community Arts Experience, I hereby assume full responsibility for any risk of bodily injury, death, or property damage and/or while using the premises or any facilities or equipment hereon. I further agree to hold harmless Community Arts Experience, their partners, directors, officers, employees, agents, and volunteers from any and all claims that may result from any action for damages, including but not limited, to such claims that may result from injury or death, accident or otherwise, during or arising in any way from said activity. I acknowledge that this General Release of Liability of Community Arts Experience, partners,directors, officers,employees, agents, and volunteers is binding on me and not my heirs, personal representatives, successors, and assigns.
*
I Acknowledge
MEDIA RELEASE: I hereby consent to the use of my name, likeness, and speech in an audiotape, videotape, internet, film or photograph made in any Community Arts Experience program activity for the business or publicity purposes of the Community Arts Experience program and its partners. I understand that any participation offers no remuneration and that my name, likeness, and speech may be edited, produced, recorded for duplication and distribution throughout the United States and abroad.I expressly release Community Arts Experience, its licensees, assignee's, affiliates and successors from any privacy, defamation, or other claims have arising out of the broadcast,exhibition, publication, or promotion of this program.
*
I Consent
I DO NOT Consent
e-SIGNATURE
e-Signature Statement
*
I certify that all the information I have given is true and accurate to the best of my knowledge and belief.
e-Signature
*
Whether digital or encrypted, the electronic signature isintended to authenticate this document and have the same force and effect as amanual signature.
Submit
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